1
|
Okafor CE, Keramat SA, Comans T, Page AT, Potter K, Hilmer SN, Lindley RI, Mangin D, Naganathan V, Etherton-Beer C. Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis. J Am Med Dir Assoc 2024; 25:539-544.e2. [PMID: 38307120 DOI: 10.1016/j.jamda.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/13/2023] [Accepted: 12/26/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVES The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia. DESIGN A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group. SETTING AND PARTICIPANTS Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019. METHODS Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars. RESULTS The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period. CONCLUSIONS AND IMPLICATIONS Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.
Collapse
Affiliation(s)
- Charles E Okafor
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Syed Afroz Keramat
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Tracy Comans
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Amy T Page
- Western Australia Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| | | | - Sarah N Hilmer
- Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia; Kolling Institute, Northern Sydney Local Health District and The University of Sydney, St Leonards, New South Wales, Australia
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia; The George Institute for Global Health, Barangaroo, Sydney, New South Wales, Australia
| | - Dee Mangin
- McMaster University, Hamilton, Ontario, Canada; University of Otago, Christchurch Central City, Christchurch, New Zealand
| | - Vasi Naganathan
- Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia; Department of Geriatric Medicine, Centre of Education and Research in Ageing, Concord Repatriation Hospital, New South Wales, Australia
| | - Christopher Etherton-Beer
- Western Australia Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
2
|
Bužančić I, Ortner Hadžiabdić M. Deprescribing in a multimorbid older adult: A case vignette study among community pharmacists and primary care physicians. Basic Clin Pharmacol Toxicol 2023; 133:729-740. [PMID: 37177977 DOI: 10.1111/bcpt.13899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/15/2023]
Abstract
Collaborative deprescribing can include pharmacists' medication review with identification and suggestion of potential deprescribing targets to physicians. Case vignettes can be a valuable method for researching variations in clinical decision making, especially in settings unaccustomed to newer clinical approaches such as deprescribing. This study aimed to explore if pharmacists can identify deprescribing targets and if physicians would accept pharmacist's deprescribing rationales. A cross-sectional study was performed using an online case vignette based on a real-life elderly patient. Pharmacists were asked to indicate which medicines they would recommend deprescribing, alongside a rationale. Physicians were asked to state their acceptance of the proposed pharmacist's deprescribing suggestion. Pharmacists gave 1275 deprescribing rationales, and most were given for deprescribing opioids, NSAID and diuretics. Physicians would accept rationales to deprescribe a median of 10 medicines, while pharmacist would recommend deprescribing a median of six medicines. Most difference lays in deprescribing of preventative medicines. Healthcare providers share agreement on deprescribing targets, but pharmacists show hesitancies in making recommendations that could hamper potential collaboration. Action is needed to improve pharmacists' skills in recognizing deprescribing targets and confidence in making suggestions, which could lead to opening of possibilities for joint patient care.
Collapse
Affiliation(s)
- Iva Bužančić
- City Pharmacies Zagreb, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | | |
Collapse
|
3
|
Pétein C, Spinewine A, Laroche ML, Niquille A, Henrard S. Adaptation and validation of the revised Patients' Attitudes towards Deprescribing (rPATD) questionnaire for benzodiazepine receptor agonists. Res Social Adm Pharm 2023:S1551-7411(23)00274-7. [PMID: 37301641 DOI: 10.1016/j.sapharm.2023.05.010] [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: 11/04/2022] [Revised: 03/17/2023] [Accepted: 05/13/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire explores older adults' views on deprescribing in general. Those views may differ, however, when the target is a specific drug such as benzodiazepine receptor agonists (BZRA). OBJECTIVE This study aimed to adapt the 22-item French rPATD questionnaire to create a BZRA-specific instrument and to assess the psychometric properties of this new tool. METHODS The adaptation of the questionnaire comprised 3 steps: 1) item transformation during group discussions with 8 healthcare providers and 8 BZRA users (aged ≥65 years), 2) pre-test of the questionnaire with 12 other older adults to ensure items understanding, 3) evaluation of the psychometric properties of the new questionnaire with 221 older BZRA users recruited in Belgium, France, and Switzerland. Construct validity was assessed using exploratory factor analysis (EFA), internal consistency with Cronbach's alpha, and test-retest reliability with intraclass correlation coefficient (ICC). RESULTS After the pre-test, the questionnaire had 24 items (19 adapted from the French rPATD, 3 removed, and 5 added). The EFA, however, found that several items performed poorly. Eleven items were consequently removed, based on statistical performance and clinical relevance. Three factors were extracted from the EFA performed on the 11 retained items and were named "Concerns about stopping BZRA", "BZRA inappropriateness", and "Dependence on BZRA". The questionnaire also includes two global questions about willingness to reduce BZRA dosage and willingness to discontinue BZRA. All factors showed acceptable internal consistency (0.68 ≤ Cronbach's alpha ≤0.74). Two factors showed acceptable test-retest reliability. The "Concerns about stopping BZRA" factor was found to vary over time (ICC [95%CI]: 0.35[-0.02; 0.64]). CONCLUSIONS We developed and validated a 13-item questionnaire to evaluate the attitudes of older people towards BZRA deprescribing. Despite some limitations, this questionnaire appears to be a useful tool for facilitating shared decision-making on BZRA deprescribing.
Collapse
Affiliation(s)
- Catherine Pétein
- Clinical Pharmacy research group, Louvain Drug Research Institute, Université catholique de Louvain, Avenue Emmanuel Mounier 72, 1200, Brussels, Belgium.
| | - Anne Spinewine
- Clinical Pharmacy research group, Louvain Drug Research Institute, Université catholique de Louvain, Avenue Emmanuel Mounier 72, 1200, Brussels, Belgium; Pharmacy Department, Université Catholique de Louvain, CHU UCL Namur, Rue Dr Gaston Therasse 1, 5530, Yvoir, Belgium.
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, 2 Avenue Martin Luther King, 87042, Limoges Cedex Limoges, France; UR 24134 Vie-Santé, Faculty of Medicine, University of Limoges, Campus Marcland, 2 Rue du Docteur Marcland, 87025, Limoges, France.
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, 1011, Lausanne, Switzerland; Community Pharmacy, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 30 Quai Ernest-Ansermet, CH-1211, Geneva 4, Switzerland.
| | - Séverine Henrard
- Clinical Pharmacy research group, Louvain Drug Research Institute, Université catholique de Louvain, Avenue Emmanuel Mounier 72, 1200, Brussels, Belgium; Institute of Health and Society (IRSS), Université Catholique de Louvain, Clos Chapelle-aux-Champs 30, 1200, Brussels, Belgium.
| |
Collapse
|
4
|
Heinrich CH, McHugh S, McCarthy S, Donovan MD. Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland. PLoS One 2022; 17:e0274552. [PMID: 36520798 PMCID: PMC9754218 DOI: 10.1371/journal.pone.0274552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/31/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective. METHODS A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework. RESULTS Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process. CONCLUSION Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.
Collapse
Affiliation(s)
- Clara H. Heinrich
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
- * E-mail:
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork City, Co. Cork, Ireland
| | - Suzanne McCarthy
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
| | - Maria D. Donovan
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
| |
Collapse
|
5
|
Hasegawa S, Mizokami F, Mase H, Hayakawa Y, Shimizu A, Matsui Y. Effects of discontinuation of antihypertensive drugs on frailty syndrome in outpatients: a 1-year prospectively designed retrospective chart-review pilot study. J Int Med Res 2022; 50:3000605221130716. [PMID: 36314740 PMCID: PMC9629568 DOI: 10.1177/03000605221130716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the effects of discontinuing antihypertensive drugs on the characteristics of patients with frailty syndrome. METHODS This prospective pilot study was conducted between March 2016 and July 2019. Among patients who visited the frailty clinic within this period, outpatients who received antihypertensive drugs at their first visit and were followed-up for about 1 year were enrolled. Participants who discontinued or continued antihypertensive drugs during 1 year of follow-up were classified into a discontinuation group or continuation group, respectively. Each domain in the Kihon checklist (KCL), fall risk score, short physical performance battery (SPPB) score, and skeletal muscle index (SMI) were assessed at the first visit and 1-year follow-up assessment, and were compared between the two groups. RESULTS Among 498 patients who attended the frailty clinic, 78 were enrolled (discontinuation group, n = 19; continuation group, n = 59). At the first visit, SMI scores were significantly higher in the discontinuation versus continuation group. At the 1-year assessment, physical strength in the KCL for the discontinuation group and various SPPB scores for both groups were significantly improved, and the fall risk score was improved in the continuation group. CONCLUSION Discontinuation of antihypertensive drugs may positively affect physical performance.
Collapse
Affiliation(s)
- Sho Hasegawa
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Japan,Sho Hasegawa, Department of Pharmacy, National Center for Geriatrics and Gerontology, 7-430 Morioka, Obu, Aichi 474-8511, Japan.
| | - Fumihiro Mizokami
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Hiroki Mase
- Department of Pharmacy, National Hospital Organization Sakakibara Hospital, Tsu, Japan
| | - Yuji Hayakawa
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Atsuya Shimizu
- Department of Cardiology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Yasumoto Matsui
- Center for Frailty and Locomotive Syndrome, National Center for Geriatrics and Gerontology, Obu, Japan
| |
Collapse
|
6
|
Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population. Geriatrics (Basel) 2022; 7:geriatrics7050097. [PMID: 36136806 PMCID: PMC9498769 DOI: 10.3390/geriatrics7050097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.
Collapse
|
7
|
Tan J, Wang M, Pei X, Sun Q, Lu C, Wang Y, Zhang L, Wu C. Continue or not to continue? Attitudes towards deprescribing among community-dwelling older adults in China. BMC Geriatr 2022; 22:492. [PMID: 35676628 PMCID: PMC9175377 DOI: 10.1186/s12877-022-03184-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Inappropriate prescribing of medications and polypharmacy among older adults are associated with a wide range of adverse outcomes. It is critical to understand the attitudes towards deprescribing—reducing the use of potentially inappropriate medications (PIMs)—among this vulnerable group. Such information is particularly lacking in low - and middle-income countries. Methods In this study, we examined Chinese community-dwelling older adults’ attitudes to deprescribing as well as individual-level correlates. Through the community-based health examination platform, we performed a cross-sectional study by personally interviews using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire (version for older adults) in two communities located in Suzhou, China. We recruited participants who were at least 65 years and had at least one chronic condition and one prescribed medication. Results We included 1,897 participants in the present study; the mean age was 73.8 years (SD = 6.2 years) and 1,023 (53.9%) were women. Most of older adults had one chronic disease (n = 1,364 [71.9%]) and took 1–2 regular drugs (n = 1,483 [78.2%]). Half of the participants (n = 947, 50%) indicated that they would be willing to stop taking one or more of their medicines if their doctor said it was possible, and 924 (48.7%) older adults wanted to cut down on the number of medications they were taking. We did not find individual level characteristics to be correlated to attitudes to deprescribing. Conclusions The proportions of participants’ willingness to deprescribing were much lower than what prior investigations among western populations reported. It is important to identify the factors that influence deprescribing and develop a patient-centered and practical deprescribing guideline that is suitable for Chinese older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03184-3.
Collapse
Affiliation(s)
- Jie Tan
- Global Health Research Center, Duke Kunshan University, Academic Building 3038 No. 8 Duke Avenue, 215316, Kunshan, Jiangsu, China
| | - MinHong Wang
- Department of Geriatric Medicine, Suzhou Municipal Hospital, Gusu School, The Affiliated Suzhou Hospital of Nanjing Medical University, Nanjing Medical University, 215002, Suzhou, Jiangsu Province, China
| | - XiaoRui Pei
- Department of Geriatric Medicine, Suzhou Municipal Hospital, Gusu School, The Affiliated Suzhou Hospital of Nanjing Medical University, Nanjing Medical University, 215002, Suzhou, Jiangsu Province, China
| | - Quan Sun
- Gusu District Wumenqiao street Nanhuan community Health Service Center, 215008, Suzhou, Jiangsu Province, China
| | - ChongJun Lu
- Gusu District Pingjiang street Loujiang community Health Service Center, 215008, Suzhou, Jiangsu Province, China
| | - Ying Wang
- Global Health Research Center, Duke Kunshan University, Academic Building 3038 No. 8 Duke Avenue, 215316, Kunshan, Jiangsu, China
| | - Li Zhang
- Department of Geriatric Medicine, Suzhou Municipal Hospital, Gusu School, The Affiliated Suzhou Hospital of Nanjing Medical University, Nanjing Medical University, 215002, Suzhou, Jiangsu Province, China.
| | - Chenkai Wu
- Global Health Research Center, Duke Kunshan University, Academic Building 3038 No. 8 Duke Avenue, 215316, Kunshan, Jiangsu, China.
| |
Collapse
|
8
|
Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients: A Focus Group Study. Drugs Aging 2022; 39:209-221. [PMID: 35187614 PMCID: PMC8934783 DOI: 10.1007/s40266-021-00918-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 12/13/2022]
Abstract
Introduction Benefits and risks of preventive medication change over time for ageing patients and deprescribing of medication may be needed. Deprescribing of cardiovascular and antidiabetic drugs can be challenging and is not widely implemented in daily practice. Objective The aim of this study was to identify barriers and enablers of deprescribing cardiometabolic medication as seen by healthcare providers (HCPs) of different disciplines, and to explore their views on their specific roles in the process of deprescribing. Methods Three focus groups with five general practitioners, eight pharmacists, three nurse practitioners, two geriatricians, and two elder care physicians were conducted in three cities in The Netherlands. Interviews were recorded and transcribed verbatim. Directed content analysis was performed on the basis of the Theoretical Domains Framework. Two researchers independently coded the data. Results Most HCPs agreed that deprescribing of cardiometabolic medication is relevant but that barriers include lack of evidence and expertise, negative beliefs and fears, poor communication and collaboration between HCPs, and lack of resources. Having a guideline was considered an enabler for the process of deprescribing of cardiometabolic medication. Some HCPs feared the consequences of discontinuing cardiovascular or antidiabetic medication, while others were not motivated to deprescribe when the patients experienced no problems with their medication. HCPs of all disciplines stated that adequate patient communication and involving the patients and relatives in the decision making enables deprescribing. Barriers to deprescribing included the use of medication initiated by specialists, the poor exchange of information, and the amount of time it takes to deprescribe cardiometabolic medication. The HCPs were uncertain about each other’s roles and responsibilities. A multidisciplinary approach including the pharmacist and nurse practitioner was seen as the best way to support the process of deprescribing and address barriers related to resources. Conclusion HCPs recognized the importance of deprescribing cardiometabolic medication as a medical decision that can only be made in close cooperation with the patient. To successfully accomplish the process of deprescribing they strongly recommended a multidisciplinary approach.
Collapse
|
9
|
Lai A, Odom A, Roskos SE, Phillips JP. Deprescribing Inappropriate Proton Pump Inhibitors in a Family Medicine Residency Practice Office. PRIMER (LEAWOOD, KAN.) 2021; 5:43. [PMID: 34841218 PMCID: PMC8612589 DOI: 10.22454/primer.2021.290175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are often prescribed beyond their medically-approved duration of use. Long-term PPI use has been linked with numerous adverse effects and contributes to polypharmacy. This study sought to understand the effect of evidence-based education to resident and faculty physicians on deprescribing inappropriate PPIs. We hypothesized that this educational intervention would result in fewer inappropriate PPI prescriptions. METHODS We performed a chart review on all adult patients in a family medicine residency program practice, identifying those inappropriately taking PPIs. All physicians in the practice participated in an educational intervention regarding deprescribing inappropriate PPIs and were given frequent reminders to continue their deprescribing efforts. We reviewed charts at the end of the study to identify patients with successful deprescribing attempts. RESULTS Of the 187 patients prescribed inappropriate PPIs in the study, 100 remained on PPIs at the end of the study (46.6% success rate). There was a significant decrease in the number of patients inappropriately prescribed PPIs by each physician over the course of the study, from a mean of 17.0 (beginning) to 9.1 (end). CONCLUSION Physician education with reminders is an effective means of reducing the number of inappropriate PPIs prescribed in a family medicine residency practice. Future studies could investigate the effectiveness of educational interventions with other medication classes that are often prescribed inappropriately.
Collapse
Affiliation(s)
- Andrew Lai
- Sparrow Hospital-Michigan State University Family Medicine Residency Program, Lansing, MI
| | - Amy Odom
- Sparrow Hospital-Michigan State University Family Medicine Residency Program, Lansing, MI
| | - Steven E Roskos
- Michigan State University College of Human Medicine and Sparrow Hospital-Michigan State University Family Medicine Residency Program, Lansing, MI
| | - Julie P Phillips
- Michigan State University College of Human Medicine and Sparrow Hospital-Michigan State University Family Medicine Residency Program, Lansing, MI
| |
Collapse
|
10
|
Tegegn HG, Gebresillassseie BM, Erku DA, Elias A, Yabeyu AB, Ayele AA. Deprescribing practice in a resource-limited setting: Healthcare providers' insights. Int J Clin Pract 2021; 75:e14356. [PMID: 33974310 DOI: 10.1111/ijcp.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 05/07/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Inappropriate polypharmacy poses risks of adverse drug events, high healthcare costs and mortality. Deprescribing could minimise inappropriate polypharmacy and the consequences thereof. The aim of this study was to evaluate healthcare providers' (HCPs') attitudes toward and experiences with deprescribing practice in Ethiopia. METHODS We conducted an institution-based cross-sectional survey among HCPs at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. We used a validated questionnaire developed by Linsky et al. The tool included questions that explore medication characteristics, current patient clinical factors, predictions of future health states, patients' resources to manage their own health and education and experience. One-way ANOVA was used to test the association between sociodemographic variables and their perception of deprescribing decisions. RESULTS Of 85 HCPs approached, about 82 HCPs completed the survey, giving a response rate of 96.5%. Most of the participants (n = 73, 89%) have scored less than 1.5 points showing they are reluctant to proactively deprescribe. Physicians seem to be affected by the significant physical health conditions (mean = 1.68) and clinical endpoint like blood pressure (mean = 1.5) to make deprescribing decisions. According to the post hoc analysis of one-way ANOVA, clinical pharmacists seemed to have a better attitude toward deprescribing decisions compared with physicians (P = .025). CONCLUSION HCPs' decision to discontinue a medication could be multifactorial. Physicians could be influenced by physical health condition and clinical endpoints for deprescribing decision. Future studies should emphasise on barriers and facilitators to deprescribing practice specific to the context in Ethiopia.
Collapse
Affiliation(s)
- Henok Getachew Tegegn
- School of Rural Medicine, Pharmacy, University of New England, Armidale, NSW, Australia
- College of Medicine and Health Science, Clinical Pharmacy Department, University of Gondar, Gondar, Ethiopia
| | | | - Daniel Asfaw Erku
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Asrat Elias
- College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Abdella Birhan Yabeyu
- Collage of Health Science, Department of Pharmacology and Clinical Pharmacy, Addis Ababa University (AAU), Addis Ababa, Ethiopia
| | - Asnakew Achaw Ayele
- College of Medicine and Health Science, Clinical Pharmacy Department, University of Gondar, Gondar, Ethiopia
- School of Health, University of New England, Armidale, NSW, Australia
| |
Collapse
|
11
|
Winata S, Liacos M, Crabtree A, Page A, Moran C. Electronic Medication Management System Introduction and Deprescribing Practice in Post-Acute Care. J Am Med Dir Assoc 2020; 22:90-95. [PMID: 33234446 DOI: 10.1016/j.jamda.2020.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/04/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effect of introducing an electronic medication management system (EMMS) on deprescribing practice in a post-acute hospital setting. DESIGN This study used a before-after study design. SETTING AND PARTICIPANTS This study examined the admission and discharge medications prescribed to patients admitted to an Australian post-acute hospital before and after the introduction of an EMMS. METHODS Data were collected over a 1-month period before and after the introduction of an EMMS and included summary measures of drug burden including Potentially Inappropriate Medications and the Drug Burden Index. We calculated and compared admission and discharge medication prescription as well as change in medication use before and after the introduction of an EMMS. RESULTS Medication prescription data were available for 121 people before and 107 people after EMMS introduction. In both phases, when compared with admission, those discharged were prescribed fewer medications (mean reduction pre-EMMS = 2.9, P < .001, post-EMMS = 2.6, P < .001), fewer Potentially Inappropriate Medications (mean reduction pre-EMMS = 0.4, P < .001, post-EMMS = 0.6, P < .001) and had lower Drug Burden Index (mean reduction pre-EMMS = 0.1, P < .001, post-EMMS = 0.2, P < .001). The degree of reduction in each measure was similar before and after EMMS introduction. CONCLUSIONS AND IMPLICATIONS The introduction of an EMMS did not affect deprescribing practice in a post-acute hospital setting. Future work is required to explore the potential for clinical decision support within an EMMS to further improve the safety and effectiveness of deprescribing within post-acute care.
Collapse
Affiliation(s)
- Susanto Winata
- Department of Rehabilitation and Aged Care, Caulfield Hospital, The Alfred, Melbourne, Victoria, Australia; Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Michelle Liacos
- Pharmacy Department, The Alfred, Melbourne, Victoria, Australia
| | - Amelia Crabtree
- Department of Rehabilitation and Aged Care, Caulfield Hospital, The Alfred, Melbourne, Victoria, Australia
| | - Amy Page
- Pharmacy Department, The Alfred, Melbourne, Victoria, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Chris Moran
- Department of Rehabilitation and Aged Care, Caulfield Hospital, The Alfred, Melbourne, Victoria, Australia; Academic Unit, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Geriatric Medicine, Peninsula Health, Melbourne, Victoria, Australia.
| |
Collapse
|
12
|
Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:3323-3332. [PMID: 32820421 PMCID: PMC7661661 DOI: 10.1007/s11606-020-06089-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/29/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION PROSPERO - CRD42019132420.
Collapse
Affiliation(s)
- Hanna E Bloomfield
- Minneapolis VA Health Care System, Minneapolis, USA.
- University of Minnesota School of Medicine, Minneapolis, USA.
- Minneapolis VA Medical Center (151), 1 Veterans Drive, Minneapolis, MN, 55417, USA.
| | - Nancy Greer
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Amy M Linsky
- VA Boston Healthcare System and Boston University School of Medicine, Boston, USA
| | | | - Todd Naidl
- Minneapolis VA Health Care System, Minneapolis, USA
| | - Orly Vardeny
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Lauren McKenzie
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| |
Collapse
|
13
|
Gnjidic D, Reeve E. Deprescribing: What do we know, and where to next? Br J Clin Pharmacol 2020; 87:722-724. [PMID: 32851681 DOI: 10.1111/bcp.14525] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 01/22/2023] Open
Affiliation(s)
- Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| |
Collapse
|
14
|
A nurse practitioner led protocol to address polypharmacy in long-term care. Geriatr Nurs 2020; 41:956-961. [PMID: 32718755 PMCID: PMC7380258 DOI: 10.1016/j.gerinurse.2020.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/01/2022]
Abstract
Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. A focus on decreasing polypharmacy as part of 60-day periodic review process in long term care facilities has the potential to improve resident outcomes and assist health care providers in improved medication management. To achieve success in decreasing polypharmacy, an interdisciplinary team with shared goals and communication is needed.
Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. This study sought to determine if a medication management protocol completed at four month intervals by nurse practitioners (NP) could impact polypharmacy and administration times for long term care residents. The data was collected as part of a Centers for Medicare and Medicaid Services (CMS) “Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents” grant. Residents were recruited from participating long-term care facilities. NP completed a medication management protocol on admission to the program and at subsequent 4-month intervals or with an acute change in condition. A total of 2442 non-duplicated individuals were seen for at least 1 visit. Although the protocol did not result in a reduction of regularly scheduled medications, the number of scheduled medication administration times did significantly decrease. NP polypharmacy assessments and recommendations are important but were insufficient to decrease the medication burden.
Collapse
|
15
|
Linsky A, Gellad W, Linder JA, Friedberg MW. Advancing the Science of Deprescribing: A Novel Comprehensive Conceptual Framework. J Am Geriatr Soc 2019; 67:2018-2022. [PMID: 31430394 PMCID: PMC6800794 DOI: 10.1111/jgs.16136] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 12/16/2022]
Abstract
Polypharmacy is common in older adults and associated with inappropriate medication use, adverse drug events, medication nonadherence, higher costs, and increased mortality compared with those without polypharmacy. Deprescribing, the clinically supervised process of stopping or reducing the dose of medications when they cause harm or no longer provide benefit, may improve outcomes. Although potentially beneficial, clinicians struggle to overcome structural, organizational, technological, and cognitive barriers to deprescribing, limiting its use in clinical practice. Deprescribing science would benefit from a unifying conceptual framework to prioritize research. Current deprescribing conceptual frameworks have made important contributions to the field but often with a focus on specific medication classes or aspects of deprescribing. To further this relatively nascent field, we developed a broader deprescribing conceptual framework that builds on prior frameworks and includes patient, prescriber, and system influences; the process of deprescribing; outcomes; and dissemination. Patient factors include patients' biology, experience, values, and preferences. Prescriber factors include rational (eg, based on explicit knowledge) and nonrational (eg, behavioral tendencies, biases, and heuristics) decision making. System factors include resources, incentives, goals, and culture that contribute to deprescribing. The framework separates the deprescribing decision from the deprescribing process. The framework captures the results of deprescribing by examining changes in clinical structures, performance processes, patient experience, health outcomes, and cost. Through testing and refinement, this novel, more comprehensive conceptual framework has the potential to advance deprescribing research by organizing the existing evidence, identifying evidence gaps, and categorizing deprescribing interventions and the settings in which they are applied. J Am Geriatr Soc 67:2018-2022, 2019.
Collapse
Affiliation(s)
- Amy Linsky
- General Internal Medicine, VA Boston Healthcare System and Boston University School of Medicine; Boston, MA
| | - Walid Gellad
- University of Pittsburgh and the VA Pittsburgh Healthcare System; Pittsburgh, PA
| | - Jeffrey A. Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; Chicago, IL
| | - Mark W. Friedberg
- RAND, Brigham and Women’s Hospital, and Harvard Medical School; Boston, MA
| |
Collapse
|
16
|
Gillespie R, Mullan J, Harrison L. Deprescribing for older adults in Australia: factors influencing GPs. Aust J Prim Health 2019; 24:463-469. [PMID: 30423283 DOI: 10.1071/py18056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/17/2018] [Indexed: 12/24/2022]
Abstract
Polypharmacy is increasing among older Australians, raising their risk of experiencing medication-related harm. As part of the prescribing continuum, deprescribing is a strategy proposed to reduce inappropriate polypharmacy. This study explored factors that influence deprescribing among Australian GPs using a new 21-item survey to measure GP attitudes and practices. The 85 GP responses indicated that many factors are supportive of deprescribing. GPs suggest that they are willing to explore their older patients' deprescribing preferences; they believe that they have enough information about the potential harms and benefits of medication to inform their deprescribing decisions and are confident to communicate this information to their patients. GPs did not consider their patients would interpret deprescribing as being 'given up on'. Limited time to review medications, poor communication between prescribers and a perception that other prescribers do not respect their role as overall coordinators of their older patients' medications were considered by respondents to be unsupportive of deprescribing. Overall, despite GPs reporting many supportive factors for deprescribing, the influence of unsupportive factors appears to remain strong, as deprescribing is not routinely considered in practice.
Collapse
Affiliation(s)
- Robyn Gillespie
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Judy Mullan
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia
| |
Collapse
|
17
|
Abstract
Aim This study aimed to explore attitudes, beliefs and experiences regarding polypharmacy and discontinuing medications, or deprescribing, among community living older adults aged ≥65 years, using ≥5 medications. It also aimed to investigate if health literacy capabilities influenced attitudes and beliefs towards deprescribing. Background Polypharmacy use is common among Australian older adults. However, little is known about their attitudes towards polypharmacy use or towards stopping medications. Previous studies indicate that health literacy levels tend to be lower in older adults, resulting in poor knowledge about medications. Methods A self-administered survey was conducted using two previously validated tools; the Patients’ Attitude Towards Deprescribing (PATD) tool to measure attitudes towards polypharmacy use and deprescribing and the All Aspects of Health Literacy Scale (AAHLS) to measure functional, communicative and critical health literacy. Descriptive statistical analysis was conducted. Findings The 137 responses showed that 80% thought all their medications were necessary and were comfortable with the number taken. Wanting to reduce the number of medications taken was associated with concerns about the amount taken (P<0.001), experiencing side effects (P<0.001), or believing that one or more medications were no longer needed (P<0.000). Those who were using ten or more medications were more likely to want to reduce the number taken (P=0.019). Most (88%) respondents would be willing to stop medication/s in the context of receiving this advice from their doctor. Willingness to consider stopping correlated with higher scores on the critical health literacy subscale (P<0.021) and overall AAHLS score (P<0.009). Those with higher scores on the overall AAHLS measure were more likely to report that they understood why their medications were prescribed (P<0.000) and were more likely to participate in decision-making (P=0.027). Opportunities to proactively consider deprescribing may be missed, as one third of the respondents could not recall a recent review of their medications.
Collapse
|
18
|
Clough AJ, Hilmer SN, Kouladjian‐O'Donnell L, Naismith SL, Gnjidic D. Health professionals' and researchers' opinions on conducting clinical deprescribing trials. Pharmacol Res Perspect 2019; 7:e00476. [PMID: 31049205 PMCID: PMC6482940 DOI: 10.1002/prp2.476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/16/2022] Open
Abstract
While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.
Collapse
Affiliation(s)
- Alexander J. Clough
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sarah N. Hilmer
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Lisa Kouladjian‐O'Donnell
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sharon L. Naismith
- Brain & Mind CentreUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
| | - Danijela Gnjidic
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
| |
Collapse
|
19
|
Bleidt BA. Deprescribing: an emerging role for pharmacists. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2019. [DOI: 10.1111/jphs.12303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Barry A. Bleidt
- Nova Southwestern University College of Pharmacy Ft. Lauderdale FL USA
| |
Collapse
|
20
|
Duffull SB, Anakin MG, Wright DFB. Understanding the process of clinical judgement for pharmacists when making clinical decisions. Res Social Adm Pharm 2019; 15:607-614. [PMID: 30115510 DOI: 10.1016/j.sapharm.2018.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 01/10/2023]
Abstract
Clinical decision-making is arguably the most important and underappreciated skill in pharmacy. It can be described as four discrete steps: information gathering, clinical reasoning and judgement and, the decision process. The information gathering and decision negotiation steps and to some extent clinical reasoning are addressed either implicitly or explicitly by practitioners and educators. Clinical judgement, however, remains a largely unexplored concept for clinical decision-making in healthcare therapeutics. It defines how practitioners arrive at a favourable treatment strategy and, due to the often complicated benefit:risk evaluations, is often linked with concepts relating to ambiguity. In this article, we use game theory to explore the judgement stage of clinical decision-making. Game theory allows us to provide a quantitative evaluation of clinical judgement and explore concepts such as ambiguity and its sources in healthcare. Clarifying the elements involved in the judgement stage of clinical decision-making will enable a better understanding of how pharmacists contribute patient care in healthcare teams.
Collapse
Affiliation(s)
- Stephen B Duffull
- School of Pharmacy, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - Megan G Anakin
- Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| |
Collapse
|
21
|
Page A, Etherton-Beer C. Undiagnosing to prevent overprescribing. Maturitas 2019; 123:67-72. [PMID: 31027680 DOI: 10.1016/j.maturitas.2019.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 12/23/2022]
Abstract
Health care focuses on controlling symptoms and managing risk factors to improve survival by avoiding future complications. Diagnoses describe a group of signs and symptoms, often implying specific aetiologies and underlying pathophysiological disease processes. The diagnosis provides a tool for the health professional to conceptualise and classify a presentation, and thus manage the condition, and can provide the patient with an explanation or validation of their experience. Not every diagnosis holds significant clinical implications. There are diagnosed conditions that do not require treatment and, moreover, where treatment has the potential for harm without the potential for benefit. Promoting investigations and diagnoses can lead to overdiagnosis related to vested interests in increased services, use of devices or therapeutics. Multiple factors drive this issue, including broadening disease definitions and cultural factors that encourage tests and treatments, as well as medicolegal factors. While the traditional medicine review process typically involved cross-referencing medicines used with current diagnoses, a more sophisticated version of this process critically reviews the medicines and associated diagnosis, giving less emphasis to diagnoses that are no longer relevant. Known as undiagnosis, this process facilitates the withdrawal of corresponding medicines used to manage those conditions. Systematically reviewing diagnoses regularly and the associated medicine management strategies could reduce prescribing. The novel ERASE process can help clinicians Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines.
Collapse
Affiliation(s)
- Amy Page
- Alfred Health, 55 Commercial Rd, Australia; Monash University, Centre for Medicine Use and Safety, Melbourne, Australia; University of Western Australia, School of Allied Health, Centre for Medicines Optimisation, Perth, Australia.
| | - Christopher Etherton-Beer
- University of Western Australia, Western Australian Centre for Health and Ageing, Australia; Department of Geriatric Medicine, School of Medicine and Pharmacology, Royal Perth Hospital Unit, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
22
|
Deprescribing in Geriatric Medicine: Challenges and Opportunities. J Am Med Dir Assoc 2018; 19:919-922. [DOI: 10.1016/j.jamda.2018.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
|