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Raju B, Chaudhary RK, L A, Babu A, Sandeep A, Mateti UV. Rationalizing prescription via deprescribing in oncology practice. J Oncol Pharm Pract 2023; 29:2007-2013. [PMID: 37847585 DOI: 10.1177/10781552231207839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE To provide an integrated approach for deprescribing practice in oncology setting. DATA SOURCES The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included. DATA SUMMARY The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing. CONCLUSION Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.
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Affiliation(s)
- Burnis Raju
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Raushan Kumar Chaudhary
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Ananthesh L
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Anjana Babu
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Ail Sandeep
- Department of Radiation Therapy and Oncology, K S Hegde Medical Academy (KSHEMA), Nitte (Deemed to be University), Mangalore, India
| | - Uday Venkat Mateti
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
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Ham L, Slotman E, Burghout C, Raijmakers NJ, van de Poll-Franse LV, van Zuylen L, Fransen HP. Potentially inappropriate end-of-life care and its association with relatives' well-being: a systematic review. Support Care Cancer 2023; 31:731. [PMID: 38055062 DOI: 10.1007/s00520-023-08198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE Potentially inappropriate end-of-life cancer care (e.g., frequent hospital admission and emergency room visits in the last month of life) is known to be associated with a poorer quality of life of patients, but research on its association with the well-being of relatives is scarce. The aim of this systematic literature review was to evaluate the association between potentially inappropriate end-of-life cancer care and relatives' well-being. METHODS We conducted a systematic search and review, and reported according to the PRISMA guideline, on the association between potentially inappropriate end-of-life cancer care and well-being of relatives before and after the death of their loved one. Pubmed, PsycInfo, Embase, and CINAHL were searched for studies published from January 2000 to July 2022. Studies' quality was assessed using the Critical Appraisal Checklists from the Joanne Briggs Institute (JBI). RESULTS We identified eight studies including 10,062 relatives (59-79% female, mean age 46-61 years, 29-72% partner). Potentially inappropriate end-of-life cancer care was associated with poorer well-being of relatives including lower quality of life, higher burden of depressive symptoms, more regret, and more feelings of unpreparedness for the patient's death. CONCLUSION Potentially inappropriate cancer care at the end-of-life is associated with poorer well-being of relatives before and after the death of their loved one. This emphasizes the importance of avoiding potentially inappropriate end-of-life cancer care, as it is both associated with poorer outcomes for relatives and patients. However, the number of studies examining this association is small, and more research is needed in this area.
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Affiliation(s)
- Laurien Ham
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands.
- Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands.
| | - Ellis Slotman
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
| | - Carolien Burghout
- Department of Hemato-Oncology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Jeroen Bosch Academy Research, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Department of Tranzo, School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Natasja Jh Raijmakers
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, CoRPS - Center for Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Heidi P Fransen
- Department of Research & Development, The Netherlands Comprehensive Cancer Organization (IKNL), PO box 19079, 3501, DB, Utrecht, The Netherlands
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McLarney M, Johnson T, Bajaj G, Lee D, Zheng J. Cancer Pain and Frailty: A Scoping Review of How Cancer Pain Is Evaluated and Treated in the Frail and Elderly. REHABILITATION ONCOLOGY 2023. [DOI: 10.1097/01.reo.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Potentially inappropriate medication use based on two deprescribing criteria and related factors in patients with terminal cancer: A cross-sectional study. J Geriatr Oncol 2023; 14:101472. [PMID: 36931198 DOI: 10.1016/j.jgo.2023.101472] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/06/2023] [Indexed: 03/17/2023]
Abstract
INTRODUCTION We aimed to estimate the nationwide prevalence of potentially inappropriate medication (PIM) use in patients with terminal cancer according to two deprescribing criteria for patients with a limited lifespan. MATERIALS AND METHODS This cross-sectional study evaluated the prevalence of PIM use using two datasets: national claims data and single-tertiary hospital data. In the claims data, patients with terminal cancer were defined as patients with cancers who died between April and June 2018 and were prescribed opioid analgesics or megestrol or were hospitalized for >90 days before the date of death. Using hospital data, patients who were enrolled in hospice care in 2019 were identified. PIM was defined according to the adjusted criteria from the Screening Tool for Older Persons' Prescriptions in frail adults with limited life expectancy (STOPPFrail) versions 1 and 2 and oncological palliative care deprescribing guidelines (OncPal) guidelines. RESULTS From the national claims data and single-tertiary hospital data, 1,558 patients and 1,243 patients were included in the analysis, respectively. In both datasets, over 60% of patients used five or more medications (claims data: 67.7%; hospital data: 63.9%), and approximately half of them used at least one PIM (claims data: 51.5%; hospital data: 43.2%). Lipid-lowering agents, acid suppressors, and hypoglycemics were common PIMs. Polypharmacy, age, and comorbid conditions, including diabetes, were associated with PIM use. DISCUSSION Approximately two-thirds and half of the patients with terminal cancer were exposed to polypharmacy and at least one PIM based on the STOPPFrail and OncPal criteria, respectively; therefore, deprescribing PIM in patients with terminal cancer is an urgent issue.
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McCaffrey N, Cheah SL, Luckett T, Phillips JL, Agar M, Davidson PM, Boyle F, Shaw T, Currow DC, Lovell M. Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial. PLoS One 2023; 18:e0282465. [PMID: 36854021 PMCID: PMC9974128 DOI: 10.1371/journal.pone.0282465] [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: 12/17/2021] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs. METHODS Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model. RESULTS Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01). CONCLUSIONS In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men. TRIAL REGISTRATION ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.
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Affiliation(s)
- Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood Campus, Burwood, VIC, Australia
- * E-mail:
| | - Seong Leang Cheah
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Jane L. Phillips
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove Brisbane, Queensland
| | - Meera Agar
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Patricia M. Davidson
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital North Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Melanie Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Azar I, Wang S, Dhillon V, Kenitz J, Lombardo D, Deano R, Mahmood S, Mamdani H, Shields AF, Philip PA, Stellini M, Schulman-Marcus J. Preferences and Attitudes of Cardiologists in Management of Patients with Cancer. Palliat Med Rep 2022; 3:279-286. [DOI: 10.1089/pmr.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ibrahim Azar
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
- IHA Hematology Oncology, Pontiac, Michigan, USA
| | - Stephani Wang
- Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Vikram Dhillon
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Jacqueline Kenitz
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Dawn Lombardo
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Roderick Deano
- Division of Cardiology, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Syed Mahmood
- Division of Cardiology, Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Hirva Mamdani
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Anthony F. Shields
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Philip Agop Philip
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Michael Stellini
- Division of Palliative Care, Department of Medicine, Wayne State University and Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Joshua Schulman-Marcus
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
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Yekedüz E, Aktaş EG, Köksoy EB, Doğan N, Ürün Y, Utkan G. The prognostic role of polypharmacy in metastatic colorectal cancer patients treated with regorafenib. Future Oncol 2022; 18:1067-1076. [PMID: 35109668 DOI: 10.2217/fon-2021-1182] [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: 11/21/2022] Open
Abstract
Aim: To evaluate polypharmacy (PP) in patients with metastatic colorectal cancer receiving regorafenib. Methods: Patients with metastatic colorectal cancer receiving regorafenib were included and divided into two categories by their PP status: PP- (<5 regular drug use/day) and PP+ (≥5 regular drug use/day). Results: 80 patients were included. 31 (38.7%) patients had PP. The median number of drugs used was three and seven in PP- and PP+ patients, respectively. Antiemetics (26.5%) and antacids (48.4%) were the most common drugs used by PP- and PP+ patients, respectively. In multivariate analysis, the risk of death was higher in PP+ patients (hazard ratio: 2.1; 95% CI: 1.2-3.7; p = 0.005). Conclusion: PP was an independent prognostic factor for overall survival in patients with metastatic colorectal cancer receiving regorafenib.
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Affiliation(s)
- Emre Yekedüz
- Department of Medical Oncology, Ankara University Faculty of Medicine, Ankara, 06590, Turkey.,Ankara University Cancer Research Institute, Ankara, 06590, Turkey
| | - Elif Gizem Aktaş
- Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara, 06590, Turkey
| | - Elif Berna Köksoy
- Department of Medical Oncology, Ankara University Faculty of Medicine, Ankara, 06590, Turkey.,Ankara University Cancer Research Institute, Ankara, 06590, Turkey
| | - Neslihan Doğan
- Medical Oncology Clinic, Prof Dr A İlhan Özdemir Training and Research Hospital, Giresun University, Giresun, 28100, Turkey
| | - Yüksel Ürün
- Department of Medical Oncology, Ankara University Faculty of Medicine, Ankara, 06590, Turkey.,Ankara University Cancer Research Institute, Ankara, 06590, Turkey
| | - Güngör Utkan
- Department of Medical Oncology, Ankara University Faculty of Medicine, Ankara, 06590, Turkey.,Ankara University Cancer Research Institute, Ankara, 06590, Turkey
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Understanding the Potential for Pharmacy Expertise in Palliative Care: The Value of Stakeholder Engagement in a Theoretically Driven Mapping Process for Research. PHARMACY 2021; 9:pharmacy9040192. [PMID: 34941624 PMCID: PMC8704289 DOI: 10.3390/pharmacy9040192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/21/2022] Open
Abstract
Potentially avoidable medication-related harm is an inherent risk in palliative care; medication management accounts for approximately 20% of reported serious incidents in England and Wales. Despite their expertise benefiting patient care, the routine contribution of pharmacists in addressing medication management failures is overlooked. Internationally, specialist pharmacist support for palliative care services remains under-resourced. By understanding experienced practices (‘what happens in the real world’) in palliative care medication management, compared with intended processes (‘what happens on paper’), patient safety issues can be identified and addressed. This commentary demonstrates the value of stakeholder engagement and consultation work carried out to inform a scoping review and empirical study. Our overall goal is to improve medication safety in palliative care. Informal conversations were undertaken with carers and various specialist and non-specialist professionals, including pharmacists. Themes were mapped to five steps: decision-making, prescribing, monitoring and supply, use (administration), and stopping and disposal. A visual representation of stakeholders’ understanding of intended medicines processes was produced. This work has implications for our own and others’ research by highlighting where pharmacy expertise could have a significant additional impact. Evidence is needed to support best practice and implementation, particularly with regard to supporting carers in monitoring and accessing medication, and communication between health professionals across settings.
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Tjia J, Lund JL, Mack DS, Mbrah A, Yuan Y, Chen Q, Osundolire S, McDermott CL. Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life. CURR EPIDEMIOL REP 2021; 8:116-129. [PMID: 34722115 PMCID: PMC8553236 DOI: 10.1007/s40471-021-00264-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Purpose of Review To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Jennifer L Lund
- Department of Epidemiology, UNC Gillings School of Global Public Health, UNC Chapel Hill, Chapel Hill, NC, USA
| | - Deborah S Mack
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Attah Mbrah
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Yiyang Yuan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Qiaoxi Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Seun Osundolire
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, AS6-2065, Worcester, MA 01605, USA
| | - Cara L McDermott
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
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Tjia J, Clayton MF, Fromme EK, McPherson ML, DeSanto-Madeya S. Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice. J Pain Symptom Manage 2021; 62:1092-1099. [PMID: 34098012 PMCID: PMC8556298 DOI: 10.1016/j.jpainsymman.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/14/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process. OBJECTIVE To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice. METHODS An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content. RESULTS Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff. CONCLUSION Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, Worcester, Massachusetts, USA.
| | | | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA; Harvard Medical School, Cambridge, Massachusetts, USA
| | | | - Susan DeSanto-Madeya
- Ariadne Labs, Boston, Massachusetts, USA; University of Rhode Island College of Nursing, Kingston, Rhode Island, USA
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11
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Deprescribing in palliative patients with cancer: a concise review of tools and guidelines. Support Care Cancer 2021; 30:2933-2943. [PMID: 34617161 PMCID: PMC8857105 DOI: 10.1007/s00520-021-06605-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022]
Abstract
Purpose Palliative cancer patients can benefit from deprescribing of potentially inappropriate medications (PIMs). Tools and guidelines developed for the geriatric population are mainly available. This systematic review gives an overview of available guidelines and tools to deprescribe for palliative cancer patients. Methods A systematic search was carried out using the databases SCOPUS and PubMed. Studies focused on palliative cancer patients were included. Results The search identified 137 studies of which 15 studies were included in this systematic review. Six of the included tools were developed specifically for cancer patients. One of these tools was externally validated and applied in several studies and settings. Guidelines or tools that were not specifically developed for cancer patients but that were applied on cohorts of palliative cancer patients were also included. Conclusion Tools developed for geriatric patients contain drugs that are not inappropriate when used in the palliative cancer care setting. Tools developed for cancer patients are more suitable and can be applied in combination with stepwise methods to individualize deprescribing per patient. The tools and guidelines described in this systematic review can be used to further implement deprescribing in the clinical routine for palliative cancer patients.
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12
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Ham L, Geijteman ECT, Aarts MJ, Kuiper JG, Kunst PWA, Raijmakers NJH, Visser LE, van Zuylen L, Brokaar EJ, Fransen HP. Use of potentially inappropriate medication in older patients with lung cancer at the end of life. J Geriatr Oncol 2021; 13:53-59. [PMID: 34366274 DOI: 10.1016/j.jgo.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/10/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Medications at the end of life should be used for symptom control. Medications which potential adverse effects outweigh their expected benefits are called 'potentially inappropriate medications' (PIMs). PIMs are related with adverse drug events and reduced quality of life. In this study, we investigated to what extent PIMs are dispensed to older patients with lung cancer in the last month of life. METHODS We selected patients with lung cancer, aged 65+, diagnosed between 2009 and 2014, and who died before April 1st 2015 from the population-based Netherlands Cancer Registry (NCR). The NCR is linked to the PHARMO Database Network, that includes medications dispensed by community pharmacies in the Netherlands. The eight PIM groups were based on the OncPal Deprescribing Guideline: aspirin, dyslipidaemia medications, antihypertensives, osteoporosis medications, peptic ulcer prophylaxis, oral hypoglycaemics, vitamins and minerals. RESULTS Data of 7864 patients with lung cancer were analyzed. Median age was 74 year (IQR = 70-79) and 67% was male. 45% of all patients received at least one PIM in their last month of life. Taking into account all dispensed medications, patients receiving PIMs received more different medications compared to those receiving no PIMs, respectively 10 (SD = 5) vs. 3 (SD = 4) different medications (P < 0.001). CONCLUSION Almost half of the older patients with lung cancer in the Netherlands received PIMs in their last month of life. Since PIM use is associated with reduced quality of life, it is important that health care professionals continue to critically assess which medication can be discontinued at the end of life.
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Affiliation(s)
- Laurien Ham
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Mieke J Aarts
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht 3528 AE, the Netherlands
| | - Peter W A Kunst
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Onze Lieve Vrouwe Gasthuis, PO box 9243, Amsterdam 1006 AE, the Netherlands
| | - Natasja J H Raijmakers
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Loes E Visser
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands; Department of Epidemiology, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands; Department of Hospital Pharmacy, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centre, De Boelelaan 1117, Amsterdam 1081 HV, the Netherlands
| | - Edwin J Brokaar
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands
| | - Heidi P Fransen
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
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13
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Cadogan CA, Murphy M, McLean S, Bennett K, Hughes CM. Development of criteria for identifying potentially inappropriate prescribing in older adults with cancer receiving palliative care (PIP-CPC). J Geriatr Oncol 2021; 12:1193-1199. [PMID: 34144924 DOI: 10.1016/j.jgo.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 05/03/2021] [Accepted: 06/10/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To develop criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults (≥65 years) with cancer who are receiving palliative care and have an estimated life expectancy of <1 year. MATERIALS AND METHODS A two-round Delphi exercise was conducted using web-based questionnaires. A panel of 18 expert stakeholders with expertise in palliative care, oncology and/or geriatric medicine across Ireland and the United Kingdom rated their level of agreement with each statement using a 5-point Likert scale and had the option of adding free-text comments throughout the questionnaire. A priori decision rules were used to accept or reject criteria. RESULTS Twenty-eight criteria were presented in Round 1. Group consensus was achieved for 15 criteria which were included in the final set of criteria. Following a review of the panel's ratings and additional comments for the remaining 13 criteria, four criteria were removed from Round 2. Group consensus was achieved for all nine criteria included in Round 2. The final set comprised 24 criteria relating to: anorexia-cachexia (n = 1); anxiety (n = 2); constipation (n = 5); delirium (n = 1); depression (n = 3); diarrhoea (n = 1); dyspnoea/breathlessness (n = 1); fatigue (n = 2); insomnia (n = 2); nausea and vomiting (n = 2); pain (n = 3); duplicate drug classes (n = 1). CONCLUSION A consensus-agreed set of prescribing criteria has been developed for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year. Future studies should examine the application and validity of these criteria.
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Affiliation(s)
- Cathal A Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Melanie Murphy
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin, Ireland
| | - Sarah McLean
- St Vincent's Private Hospital, Merrion Road, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, United Kingdom
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14
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Whitman A, Erdeljac P, Jones C, Pillarella N, Nightingale G. Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings. DRUG HEALTHCARE AND PATIENT SAFETY 2021; 13:101-116. [PMID: 33953612 PMCID: PMC8092848 DOI: 10.2147/dhps.s255893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022]
Abstract
The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Paige Erdeljac
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Nicole Pillarella
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
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15
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Li Y, Whelan CM, Husain AF. Deprescribing in the Home Palliative Setting. J Palliat Med 2020; 24:1030-1035. [PMID: 33326319 DOI: 10.1089/jpm.2020.0376] [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: 11/13/2022] Open
Abstract
Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.
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Affiliation(s)
- Yifan Li
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ciara M Whelan
- Temmy Latner Centre for Palliative Care, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Amna F Husain
- Temmy Latner Centre for Palliative Care Lunenfeld Tanenbaum Research Institute, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
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16
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Haider S, Descallar J, Moylan E, Chua W. Polypharmacy and the use of low or limited value medications in advanced cancer. Intern Med J 2020; 51:1891-1896. [PMID: 33305887 DOI: 10.1111/imj.14964] [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: 04/01/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with advanced malignancy are often on medications for co-morbidities, including those for primary or secondary prevention. The benefit from these medications can be limited and may result in adverse effects, interact with medications used for the malignancy or associated symptoms, increase pill burden and reduce quality of life. AIMS To evaluate the proportion of patients with advanced malignancy that were continued on low or limited value medications and identify the factors associated with this. We also sought to determine how prevalent polypharmacy was within this group of patients and the factors associated with this. METHODS A retrospective chart review was conducted of patients with incurable malignancy admitted under medical oncology at Liverpool Hospital over a 90-day period. Demographic variables, co-morbidities, disease related parameters and medications were reviewed. Criteria were established to identify low or limited value medications. RESULTS Seventy-eight patients were identified between September and December 2018. Thirty-day mortality was 33%. Sixty-five percent of the cohort was on five or more medications and 24% on 10 or more. One low or limited value medication was reported in 36% and 20% were on two or more. Age ≤60 years was associated with a risk of being on at least one unnecessary medication. Patients with fewer co-morbidities and those in their last 3 months of life were significantly less likely to have polypharmacy. Nine percent of the cohort was on three or more antihypertensives and 6% of patients were on three or more oral hypoglycaemics. CONCLUSION Polypharmacy and continued prescribing of low or limited value medications was identified in a high proportion of patients. Further studies are needed to assess the impact of continuing these medications, as well as investigation of patient and physician attitudes towards de-escalation.
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Affiliation(s)
- Sana Haider
- Liverpool Cancer Therapy Centre, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
| | - Joseph Descallar
- Ingham Institute for Applied Medical Research, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
| | - Eugene Moylan
- Liverpool Cancer Therapy Centre, New South Wales, Australia
| | - Wei Chua
- Liverpool Cancer Therapy Centre, New South Wales, Australia.,Ingham Institute for Applied Medical Research, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
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17
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Use of Non-Cancer Medications in New Zealand Women at the Diagnosis of Primary Invasive Breast Cancer: Prevalence, Associated Factors and Effects on Survival. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217962. [PMID: 33138255 PMCID: PMC7663632 DOI: 10.3390/ijerph17217962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 11/17/2022]
Abstract
Background: Assessing the use of multiple medications in cancer patients is crucial as such use may affect cancer outcomes. This study reports the prevalence of non-cancer medication use at breast cancer diagnosis, its associated factors, and its effect on survival. Methods: We identified all women diagnosed with primary invasive breast cancer between 1 January 2007 and 31 December 2016, from four population-based breast cancer registries, in Auckland, Waikato, Wellington, and Christchurch, New Zealand. Through linkage to the pharmaceutical records, we obtained information on non-cancer medications that were dispensed for a minimum of 90 days’ supply between one year before cancer diagnosis and first cancer treatment. We performed ordered logistic regressions to identify associated factors and Cox regressions to investigate its effect on patient survival. Results: Of 14,485 patients, 52% were dispensed at least one drug (mean—1.3 drugs; maximum—13 drugs), with a higher prevalence observed in patients who were older, treated at a public facility, more economically deprived, and screen-detected. The use of 2–3 drugs showed a reduced non-breast cancer mortality (HR = 0.75, 95%CI = 0.60–0.92) in previously hospitalised patients, with other groups showing non-significant associations when adjusted for confounding factors. Drug use was not associated with changes in breast cancer-specific mortality. Conclusions: Non-cancer medication use at breast cancer diagnosis was common in New Zealand, more prevalent in older and disadvantaged women, and showed no effect on breast cancer-specific mortality, but a reduction in other cause mortality with the use of 2–3 drugs.
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18
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The influence of polypharmacy, potentially inappropriate medications, and drug interactions on treatment completion and prognosis in older patients with ovarian cancer. J Geriatr Oncol 2020; 11:593-602. [DOI: 10.1016/j.jgo.2019.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/07/2019] [Accepted: 12/16/2019] [Indexed: 12/27/2022]
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19
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The impact of palliative care consults on deprescribing in palliative cancer patients. Support Care Cancer 2019; 28:4107-4113. [DOI: 10.1007/s00520-019-05234-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022]
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20
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Hong S, Lee JH, Chun EK, Kim KI, Kim JW, Kim SH, Lee YG, Hwang IG, Kim JY, Koh SJ, Ko YH, Shin SH, Woo IS, Kim TY, Baek JY, Kim HJ, Kim HJ, Lee MA, Kwon JH, Hong YS, Ryoo HM, Kim JH. Polypharmacy, Inappropriate Medication Use, and Drug Interactions in Older Korean Patients with Cancer Receiving First-Line Palliative Chemotherapy. Oncologist 2019; 25:e502-e511. [PMID: 32162799 DOI: 10.1634/theoncologist.2019-0085] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 10/14/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Polypharmacy is an important issue in the care of older patients with cancer, as it increases the risk of unfavorable outcomes. We estimated the prevalence of polypharmacy, potentially inappropriate medication (PIM) use, and drug-drug interactions (DDIs) in older patients with cancer in Korea and their associations with clinical outcomes. SUBJECTS, MATERIALS, AND METHODS This was a secondary analysis of a prospective observational study of geriatric patients with cancer undergoing first-line palliative chemotherapy. Eligible patients were older adults (≥70 years) with histologically diagnosed solid cancer who were candidates for first-line palliative chemotherapy. All patients enrolled in this study received a geriatric assessment (GA) at baseline. We reviewed the daily medications taken by patients at the time of GA before starting chemotherapy. PIMs were assessed according to the 2015 Beers criteria, and DDIs were assessed by a clinical pharmacist using Lexi-comp Drug Interactions. We evaluated the association between polypharmacy and clinical outcomes including treatment-related toxicity, and hospitalization using logistic regression and Cox regression analyses. RESULTS In total, 301 patients (median age 75 years; range, 70-93) were enrolled; the most common cancer types were colorectal cancer (28.9%) and lung cancer (24.6%). Mean number of daily medications was 4.7 (±3.1; range, 0-14). The prevalence of polypharmacy (≥5 medications) was 45.2% and that of excessive polypharmacy (≥10 medications) was 8.6%. PIM use was detected in 137 (45.5%) patients. Clinically significant DDIs were detected in 92 (30.6%) patients. Polypharmacy was significantly associated with hospitalization or emergency room (ER) visits (odds ratio: 1.73 [1.18-2.55], p < .01). Neither polypharmacy nor PIM use showed association with treatment-related toxicity. CONCLUSION Polypharmacy, PIM use, and potential major DDIs were prevalent in Korean geriatric patients with cancer. Polypharmacy was associated with a higher risk of hospitalization or ER visits during the chemotherapy period. IMPLICATIONS FOR PRACTICE This study, which included 301 older Korean patients with cancer, highlights the increased prevalence of polypharmacy in this population planning to receive palliative chemotherapy. The prevalence of polypharmacy and excessive polypharmacy was 45.2% and 8.6%, respectively. The prescription of potentially inappropriate medications (PIMs) was detected in 45.5% and clinically significant drug-drug interaction in 30.6% of patients. Given the association of polypharmacy with increased hospitalization or emergency room visits, this study points to the need for increased awareness and intervention to minimize polypharmacy in the geriatric cancer population undergoing chemotherapy. Moreover, specific criteria for establishing PIMs should be adopted for the treatment of older adults with cancer.
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Affiliation(s)
- Soojung Hong
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ju Hyun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Eun Kyeong Chun
- Department of Pharmacy, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Se Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Yun-Gyoo Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - In Gyu Hwang
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, College of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Yoon Ho Ko
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Seong Hoon Shin
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Pusan, Republic of Korea
| | - In Sook Woo
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Baek
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Hyun Jung Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Myung Ah Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hun-Mo Ryoo
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University College of Medicine, Daegu, Republic of Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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21
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission. J Gen Intern Med 2019; 34:2029-2037. [PMID: 31346909 PMCID: PMC6816724 DOI: 10.1007/s11606-019-05152-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 02/06/2019] [Accepted: 05/01/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment. OBJECTIVE To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes. DESIGN Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database. PATIENTS Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035). MAIN MEASURES Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation. KEY RESULTS Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02). CONCLUSIONS A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.
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Affiliation(s)
- Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, UTHealth McGovern Medical School, Houston, TX, USA
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Dima M Qato
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.
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22
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Wenedy A, Lim YQ, Lin Ronggui CK, Koh GCH, Chong PH, Chew LST. A Study of Medication Use of Cancer and Non-Cancer Patients in Home Hospice Care in Singapore: A Retrospective Study from 2011 to 2015. J Palliat Med 2019; 22:1243-1251. [DOI: 10.1089/jpm.2018.0559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Aldo Wenedy
- Department of Pharmacy, National Cancer Center Singapore, Singapore
| | - Yong Quan Lim
- Department of Pharmacy, National University of Singapore, Singapore
| | | | - Gerald Choon Huat Koh
- Saw Swee Hock School of Public Health and Yong Loo Lin School of Medicine, National University of Singapore/National University Health System, Singapore
| | | | - Lita Sui Tjien Chew
- Department of Pharmacy, National Cancer Center Singapore, Singapore
- Department of Pharmacy, National University of Singapore, Singapore
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23
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Abstract
The use of multiple medications is common in palliative care, putting patients at risk of adverse events and a high tablet burden. Deprescribing is the process of reviewing and stopping potentially inappropriate medications in order to improve quality of life. Barriers to deprescribing exist meaning many patients will take multiple medications despite being in the final months of life. The OncPal deprescribing guideline is a useful tool to support the process for patients with a limited life expectancy. There is evidence for the safety of stopping certain medications, particularly those aimed at primary prevention. A systematic process of reviewing individual medications and their appropriateness is recommended.
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Affiliation(s)
- Jo Thompson
- Royal Surrey County Hospital / St Luke's Cancer Centre, Guildford, UK
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24
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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25
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Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing. J Hosp Palliat Nurs 2019; 21:312-318. [PMID: 31033645 DOI: 10.1097/njh.0000000000000574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses' perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
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Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. The Use of Antidiabetic, Antihypertensive, and Lipid-lowering Medications in the Elderly Dying with Advanced Cancer. Indian J Palliat Care 2019; 25:124-126. [PMID: 30820114 PMCID: PMC6388588 DOI: 10.4103/ijpc.ijpc_96_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Maintenance of medications that are unconducive to the quality of life is difficult to justify in dying terminally-ill cancer patients. Objective We aimed at determining the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with cancer. Methods We reviewed the medical records of patients above 60 years of age with advanced cancer who died in a palliative care unit. The collected data included the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life. Results Of 103 patients, 51.5% were female and the median age was 69 years. The most common cancers included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced cancer and 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. During their last week of life, 38.8% received antidiabetic, 23.3% received antihypertensive, and 3.9% received lipid-lowering agents. The data showed that 68.5% of people with diabetes received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemics received lipid-lowering agents. Hypoglycemia was reported in 7.5% of patients receiving antidiabetic drugs, while hypotension was reported in 66.7% of patients receiving antihypertensive agents. Conclusion Many elderly patients dying with advanced cancer in a palliative care unit were maintained on medications for chronic conditions until the very late stages of their lives. For such imminently dying patients, benefits of such medications are unlikely and burdens are possible. Further research is needed to explore physicians' justifications, if any, for maintaining such patients on apparently futile medications.
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Affiliation(s)
| | - Mahmoud Yassein Sroor
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Ali Ghareeb
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Enas Noshy Aboulela
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Edesa
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Morio K, Maeda I, Yokota I, Niki K, Murata T, Matsumura Y, Uejima E. Risk Factors for Polypharmacy in Elderly Patients With Cancer Pain. Am J Hosp Palliat Care 2019; 36:598-602. [DOI: 10.1177/1049909118824031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kayoko Morio
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | | | - Isao Yokota
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyuki Niki
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | - Taizo Murata
- Department of Medical Information, Osaka University Medical Hospital, Osaka, Japan
| | - Yasushi Matsumura
- Department of Medical Information, Osaka University Medical Hospital, Osaka, Japan
| | - Etsuko Uejima
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
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Use of Nonpalliative Medications Following Burdensome Health Care Transitions in Hospice Patients. Med Care 2019; 57:13-20. [DOI: 10.1097/mlr.0000000000001008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Esteban Jiménez Ó, Arroyo Aniés MP, Vicens Caldentey C, González Rubio F, Hernández Rodríguez MÁ, Sempere Manuel M. [Deprescribing to increase people health or when deprescribing could be the best pill]. Aten Primaria 2018; 50 Suppl 2:70-79. [PMID: 30279013 PMCID: PMC6837147 DOI: 10.1016/j.aprim.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/01/2018] [Accepted: 09/03/2018] [Indexed: 11/18/2022] Open
Abstract
The increasing longevity of the population, the increase in morbidity and the consumption of medications have caused that polypharmacy is a priority health problem due to its consequences: increase of adverse effects, pharmacological interactions and favor the functional deterioration of the patient. The clinical situation of the patients changes over time and it is necessary to adjust the medication in each stage, assessing the fragility, the level of dependence and the functional deterioration. Deprescription is complex and requires an adequate clinical and pharmacological formation. In Primary Care lies the greater knowledge of the patient and their environment, and in a shared way with the patient and caregivers, it is necessary to assess which drugs to maintain and which ones to withdraw from a clinical, ethical and social perspective. There are tools to help deprescription that can be useful for Primary Care to facilitate this process and that are detailed in this article.
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Affiliation(s)
- Óscar Esteban Jiménez
- Centro de Salud Borja, Zaragoza, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC.
| | - María Pilar Arroyo Aniés
- Centro de Salud Huarte, Navarra, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC
| | - Caterina Vicens Caldentey
- Centro de Salud Son Serra-La Vileta. Ib-salut, Palma de Mallorca, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC
| | - Francisca González Rubio
- Grupo EpiChron de investigación en enfermedades crónicas, Centro de Salud Delicias Sur, Zaragoza, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC
| | - Miguel Ángel Hernández Rodríguez
- Unidad de Apoyo-Plan de Salud, Dirección del Servicio Canario de la Salud, Santa Cruz de Tenerife, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC
| | - Mara Sempere Manuel
- Centro de Salud Sueca, Valencia, España; Grupo de Trabajo de Utilización de Fármacos de la SemFYC
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Gonçalves F. Deprescription in Advanced Cancer Patients. PHARMACY 2018; 6:E88. [PMID: 30134513 PMCID: PMC6164016 DOI: 10.3390/pharmacy6030088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/15/2018] [Accepted: 08/18/2018] [Indexed: 11/16/2022] Open
Abstract
The use of multiple drugs is often referred to as polypharmacy, although this term has not been precisely defined. Frequently, drugs are used unwisely in multiple combinations increasing the risk of adverse reactions, or for the long-term prevention of diseases in patients with a short life expectancy who, therefore, will not benefit from them. The reflection on this has led to the introduction of the concept of deprescription. There are many reasons for the inappropriate drug prescription and barriers to reduce medications. Tools were developed to help prescribers to limit the number of prescribed drugs that patients are taking. Several studies have shown that deprescription of some drugs is possible and safe and can even have a positive influence on wellbeing, cognitive function, falls, and admission to a hospital. Deprescription should be individualized and carried out, as far as possible, in agreement with patients and their families. A six-step method for deprescription is proposed.
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Affiliation(s)
- Ferraz Gonçalves
- Palliative Care Service, Instituto Português de Oncologia, R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
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Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus. Eur J Clin Pharmacol 2018; 74:1333-1342. [PMID: 29934849 PMCID: PMC6132505 DOI: 10.1007/s00228-018-2507-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/14/2018] [Indexed: 01/01/2023]
Abstract
Background Clinical guidance is needed to initiate, continue, and discontinue drug treatments near the end of life. Aim To identify drugs and drug classes most often adequate, questionable, or inadequate for older people at the end of life. Design Delphi consensus survey. Setting/participants Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries. Panelists were asked to characterize drug classes as “often adequate,” “questionable,” or “often inadequate” for use in older adults aged 75 years or older with an estimated life expectancy of ≤ 3 months. We distinguished the continuation of a drug class that was previously prescribed from the initiation of a new drug. Consensus was considered achieved for a given drug or drug class if the level of agreement was ≥ 75%. Results The expert panel reached consensus on a set of 14 drug classes deemed as “often adequate,” 28 drug classes deemed “questionable,” and 10 drug classes deemed “often inadequate” for continuation during the last 3 months of life. Regarding the initiation of new drug treatments, the panel reached consensus on a set of 10 drug classes deemed “often adequate,” 23 drug classes deemed “questionable,” and 23 drug classes deemed “often inadequate”. Consensus remained unachieved for some very commonly prescribed drug treatments (e.g., proton-pump inhibitors, furosemide, haloperidol, olanzapine, zopiclone, and selective serotonin reuptake inhibitors). Conclusion In the absence of high-quality evidence from randomized clinical trials, these consensus-based criteria provide guidance to rationalize drug prescribing for older adults near the end of life. Electronic supplementary material The online version of this article (10.1007/s00228-018-2507-4) contains supplementary material, which is available to authorized users.
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Hjermstad MJ, Kaasa S, Dilles T, De Laat M, Van Belle S, Christiaens T, Deliens L. Changes in medication use in a cohort of patients with advanced cancer: The international multicentre prospective European Palliative Care Cancer Symptom study. Palliat Med 2018; 32:775-785. [PMID: 29243546 DOI: 10.1177/0269216317746843] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Information on medication use in the last months of life is limited. AIM To describe which medications are prescribed and deprescribed in advanced cancer patients receiving palliative care in relation to time before death and to explore associations with demographic variables. DESIGN Prospective study, using case report forms for monthly data collection. Medication included cancer treatment and 19 therapeutic groups, grouped into four categories for: (1) cancer therapy, (2) specific cancer-related symptom relief, (3) other symptom relief and (4) long-term prevention. Data were analysed retrospectively using death as the index date. We compared medication use at 5, 4, 3, 2 and 1 month(s) before death by constructing five cross-sectional subsamples with medication use during that month. Paired analyses were done on a subsample of patients with at least two assessments before death. SETTING/PARTICIPANTS We studied the medication use of 720 patients (mean age 67, 56% male) in 30 cancer centres representing 12 countries. RESULTS From 5 to 1 month(s) before death, cancer therapy decreased (55%-24%), most medications for symptom relief increased, for example, opioids (62%-81%) and sedatives (35%-46%), but medication for long-term prevention decreased (38%-27%). The prevalence of chemotherapy was 15.5% in the last month of life, with 9% of new courses started in the last 2 months. With higher age, chemotherapy and opioid use decreased. CONCLUSION Medications for symptom relief increased in almost all medication groups. Deprescribing was found in heart medication/anti-hypertensives and cancer therapy, although use of the latter remained relatively high.
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Affiliation(s)
- Kristel Paque
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Monique Elseviers
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Robert Vander Stichele
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Marianne J Hjermstad
- 3 European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,4 Regional Advisory Unit for Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- 3 European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,5 Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tinne Dilles
- 6 Department of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Martine De Laat
- 7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Simon Van Belle
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Medicare Part D Use of Older Medicare Beneficiaries Admitted to Hospice. J Am Geriatr Soc 2018; 66:937-944. [DOI: 10.1111/jgs.15328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick M. Zueger
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
| | - Holly M. Holmes
- Division of Geriatric and Palliative MedicineUTHealth McGovern Medical SchoolHouston Texas
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
- Division of Public Health Sciences, Epidemiology ProgramFred Hutchinson Cancer Research CenterSeattle Washington
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - A. Simon Pickard
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
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Whitty R, Porter S, Battu K, Bhatt P, Koo E, Kalocsai C, Wu P, Delicaet K, Bogoch II, Wu R, Downar J. A pilot study of a Medication Rationalization (MERA) intervention. CMAJ Open 2018; 6:E87-E94. [PMID: 29467186 PMCID: PMC5878954 DOI: 10.9778/cmajo.20170134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many seriously ill and frail inpatients receive potentially inappropriate or harmful medications and do not receive medications for symptoms of advanced illness. We developed and piloted an interprofessional Medication Rationalization (MERA) approach to deprescribing inappropriate medications and prescribing appropriate comfort medications. METHODS We conducted a single-centre pilot study of inpatients at risk of 6-month mortality from advanced age or morbidity. The MERA team reviewed the patients' medications and made recommendations on the basis of guidelines. We measured end points for feasibility, acceptability, efficiency and effectiveness. RESULTS We enrolled 61 of 115 (53%) eligible patients with a mean age of 79.6 years (standard deviation [SD] 11.7 yr). Patients were taking an average of 11.5 (SD 5.2) medications before admission and had an average of 2.1 symptoms with greater than 6/10 severity on the revised Edmonton Symptom Assessment System. The MERA team recommended 263 medication changes, of which 223 (85%) were accepted by both the medical team and the patient. MERA team's recommendations resulted in the discontinuation of 162 medications (mean 3.1 per patient), dose changes for 48 medications (mean 0.9 per patient) and the addition of 13 medications (mean 0.2 per patient). Patients who received the MERA intervention stopped significantly more inappropriate medications than similar non-MERA comparison patients for whom data were collected retrospectively (3.1 v. 0.9 medications per patient, p < 0.01). The MERA approach was highly acceptable to patients and medical team members. INTERPRETATION The MERA intervention is feasible, acceptable, efficient and possibly effective for changing medication use among seriously ill and frail elderly inpatients. Scalability and effectiveness may be improved through automation and integration with medication reconciliation programs.
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Affiliation(s)
- Rachel Whitty
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Sandra Porter
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Kiran Battu
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Pranjal Bhatt
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Ellen Koo
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Csilla Kalocsai
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Peter Wu
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Kendra Delicaet
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Isaac I Bogoch
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - Robert Wu
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
| | - James Downar
- Affiliations: Departments of Pharmacy (Whitty, Porter, Battu, Bhatt) and Medicine (Koo, R. Wu, P.E. Wu, Bogach, Downar) and Centre for Innovation in Complex Care (Delicaet), University Health Network; Centre for Addiction and Mental Health (Kalocsai), Toronto, Ont
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Jodat YA, Kang MG, Kiaee K, Kim GJ, Martinez AFH, Rosenkranz A, Bae H, Shin SR. Human-Derived Organ-on-a-Chip for Personalized Drug Development. Curr Pharm Des 2018; 24:5471-5486. [PMID: 30854951 PMCID: PMC6587585 DOI: 10.2174/1381612825666190308150055] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/22/2022]
Abstract
To reduce the required capital and time investment in the development of new pharmaceutical agents, there is an urgent need for preclinical drug testing models that are predictive of drug response in human tissues or organs. Despite tremendous advancements and rigorous multistage screening of drug candidates involving computational models, traditional cell culture platforms, animal models and most recently humanized animals, there is still a large deficit in our ability to predict drug response in patient groups and overall attrition rates from phase 1 through phase 4 of clinical studies remain well above 90%. Organ-on-a-chip (OOC) platforms have proven potential in providing tremendous flexibility and robustness in drug screening and development by employing engineering techniques and materials. More importantly, in recent years, there is a clear upward trend in studies that utilize human-induced pluripotent stem cell (hiPSC) to develop personalized tissue or organ models. Additionally, integrated multiple organs on the single chip with increasingly more sophisticated representation of absorption, distribution, metabolism, excretion and toxicity (ADMET) process are being utilized to better understand drug interaction mechanisms in the human body and thus showing great potential to better predict drug efficacy and safety. In this review, we summarize these advances, highlighting studies that took the next step to clinical trials and research areas with the utmost potential and discuss the role of the OOCs in the overall drug discovery process at a preclinical and clinical stage, as well as outline remaining challenges.
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Affiliation(s)
- Yasamin A Jodat
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA 02139, United States
- Department of Mechanical Engineering, Stevens Institute of Technology, New Jersey, 07030, United States
| | - Min G Kang
- Department of Bioindustrial Technologies, College of Animal Bioscience and Technology, Konkuk University, Seoul 05029, Korea
| | - Kiavash Kiaee
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA 02139, United States
- Department of Mechanical Engineering, Stevens Institute of Technology, New Jersey, 07030, United States
| | - Gyeong J Kim
- Department of Bioindustrial Technologies, College of Animal Bioscience and Technology, Konkuk University, Seoul 05029, Korea
| | - Angel F H Martinez
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA 02139, United States
- ALPHA Medical Leadership Program, Anahuac University, School of Medicine, Mexico
| | - Aliza Rosenkranz
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA 02139, United States
| | - Hojae Bae
- Department of Stem Cell and Regenerative Biotechnology, KU Convergence Science and Technololgy Institute, Konkuk University, Seoul, 05029, Korea
| | - Su R Shin
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA 02139, United States
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Polypharmacy in Older Adults with Cancer: Evaluating Polypharmacy as Part of the Geriatric Assessment. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0221-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Perspectives of patients, close relatives, nurses, and physicians on end-of-life medication management. Palliat Support Care 2017; 16:580-589. [DOI: 10.1017/s1478951517000761] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACTObjective:Our aim was to gain insight into the perspectives of patients, close relatives, nurses, and physicians on medication management for patients with a life expectancy of less than 3 months.Method:We conducted an empirical multicenter study with a qualitative approach, including in-depth interviews with patients, relatives, nurses, specialists, and general practitioners (GPs). We used the constant comparative method and ATLAS.ti (v. 7.1) software for our analysis.Results:Saturation occurred after 18 patient cases (76 interviews). Some 5 themes covering 18 categories were identified: (1) priorities in end-of-life care, such as symptom management and maintaining hope; (2) appropriate medication use, with attention to unnecessary medication and deprescription barriers; (3) roles in decision making, including physicians in the lead, relatives' advocacy, and pharmacists as suppliers; (4) organization and communication (e.g., transparency of tasks and end-of-life conversations); and (5) prerequisites about professional competence, accessibility and quality of medical records, and financial awareness. Patients, relatives, nurses, specialists, and GPs varied in their opinions about these themes.Significance of Results:This study adds to our in-depth understanding of the complex practice of end-of-life medication management. It provides knowledge about the diversity of the perspectives of patients, close relatives, nurses, and physicians regarding beliefs, attitudes, knowledge, skills, behavior, work setting, the health system, and cultural factors related to the matter. Our results might help to draw an interdisciplinary end-of-life medication management guide aimed at stimulating a multidisciplinary and patient-centered pharmacotherapeutic care approach.
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Poudel A, Yates P, Rowett D, Nissen LM. Use of Preventive Medication in Patients With Limited Life Expectancy: A Systematic Review. J Pain Symptom Manage 2017; 53:1097-1110.e1. [PMID: 28192226 DOI: 10.1016/j.jpainsymman.2016.12.350] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/05/2016] [Accepted: 12/29/2016] [Indexed: 01/20/2023]
Abstract
CONTEXT Optimal prescribing in patients with limited life expectancy (LLE) remains unclear. OBJECTIVES This study systematically reviews the published literature regarding the use of preventive medication in patients with reduced life expectancy. METHODS A systematic literature search was conducted using three databases (MEDLINE, EMBASE, and CINAHL). Articles published in English from January 1995 to December 2015 were retrieved for analysis to identify peer-reviewed, observational studies assessing use of preventive medications in patients with LLE. Inclusion criteria were: patients with a LLE (less than or equal to two years); prescribed/used preventive medications. RESULTS Of the 15 studies meeting our eligibility criteria, six were from inpatient hospital settings, five in palliative care, three in nursing homes, and one in community settings. The most common life-limiting illnesses described in the studies were cancer (n = 6), cardiovascular diseases (n = 4), dementia and cognitive impairment (n = 2), and other life-limiting illnesses (n = 3). Lipid-lowering medications, especially the statins were frequently prescribed preventive medication followed by antiplatelets, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, anti-osteoporosis medications, and calcium channel blockers. Only four studies reported the instances of medication withdrawal. CONCLUSION Patients continue to receive medications that are not prescribed as symptomatic treatment despite having a LLE. Very few rigorous studies have been conducted on minimizing preventive medications in patients with LLE, and expert opinion varies on medication optimization at the end of life. A consensus guideline that addresses this gap is of paramount importance.
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Affiliation(s)
- Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Debra Rowett
- Repatriation General Hospital, Adelaide, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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Smith A, Murphy L, Bennett K, Barron TI. Patterns of statin initiation and continuation in patients with breast or colorectal cancer, towards end-of-life. Support Care Cancer 2017; 25:1629-1637. [PMID: 28101676 PMCID: PMC5378743 DOI: 10.1007/s00520-017-3576-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/09/2017] [Indexed: 01/06/2023]
Abstract
Purpose Cross-sectional studies show that statins, used in cardiovascular disease prevention, are often discontinued approaching death. Studies investigating associations between statin exposure and cancer outcomes, not accounting for these exposure changes, are prone to reverse causation bias. The aim of this study was to describe longitudinally the changes in statin initiation and continuation prior to death in patients with breast or colorectal cancer, thus establishing an appropriate exposure lag time. Methods This study was carried out using linked cancer registry and prescribing data. We identified patients who died of their cancer (cases) and cancer survivors were used as controls. The probability of initiating or continuing statin use was estimated up to 5 years prior to death (or index date). Conditional binomial models were used to estimate relative risks and risk differences for associations between approaching cancer death and statin use. Results Compared to controls, the probability of continued statin use in breast cancer cases was significantly lower 3 months prior to death (RR 0.86 95% CI 0.79, 0.94). Similarly, in colorectal cancer cases, the probability of continued statin use was significantly lower 3 months prior to colorectal cancer death (RR 0.77 95% CI 0.68, 0.88). Conclusion A significant proportion of patients will cease statin treatment in the months prior to a colorectal or breast cancer death. Electronic supplementary material The online version of this article (doi:10.1007/s00520-017-3576-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amelia Smith
- Trinity Centre for Health Sciences, Trinity College, University of Dublin, Dublin, Ireland. .,Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland.
| | - Laura Murphy
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas I Barron
- Trinity Centre for Health Sciences, Trinity College, University of Dublin, Dublin, Ireland.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Oliveira L, Ferreira MO, Rola A, Magalhães M, Ferraz Gonçalves J. Deprescription in Advanced Cancer Patients Referred to Palliative Care. J Pain Palliat Care Pharmacother 2016; 30:201-5. [DOI: 10.1080/15360288.2016.1204411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sharma M, Loh KP, Nightingale G, Mohile SG, Holmes HM. Polypharmacy and potentially inappropriate medication use in geriatric oncology. J Geriatr Oncol 2016; 7:346-53. [PMID: 27498305 DOI: 10.1016/j.jgo.2016.07.010] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/22/2016] [Accepted: 07/18/2016] [Indexed: 01/04/2023]
Abstract
Polypharmacy is a highly prevalent problem in older persons, and is challenging to assess and improve due to variations in definitions of the problem and the heterogeneous methods of medication review and reduction. The purpose of this review is to summarize evidence regarding the prevalence and impact of polypharmacy in geriatric oncology patients and to provide recommendations for assessment and management. Polypharmacy has somewhat variably been incorporated into geriatric assessment studies in geriatric oncology, and polypharmacy has not been consistently evaluated as a predictor of negative outcomes in patients with cancer. Once screened, interventions for polypharmacy are even more uncertain. There is a great need to create standardized interventions to improve polypharmacy in geriatrics, and particularly in geriatric oncology. The process of deprescribing is aimed at reducing medications for which real or potential harm outweighs benefit, and there are numerous methods to determine which medications are candidates for deprescribing. However, deprescribing approaches have not been evaluated in older patients with cancer. Ultimately, methods to identify polypharmacy will need to be clearly defined and validated, and interventions to improve medication use will need to be based on clearly defined and standardized methods.
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Affiliation(s)
- Manvi Sharma
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA.
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
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Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28:456-69. [PMID: 27353273 DOI: 10.1093/intqhc/mzw060] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
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Affiliation(s)
- M Cardona-Morrell
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia
| | - Jch Kim
- School of Medicine, Ground floor, 30, Western Sydney University, Narellan Road & Gilchrist Drive, Campbelltown NSW 2560, Australia
| | - R M Turner
- School of Public Health and Community Medicine, Level 2, Samuels Building, Samuels Ave, The University of New South Wales, Kensington NSW 2033, Australia
| | - M Anstey
- Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Perth WA 6009, Australia
| | - I A Mitchell
- Intensive Care Unit, Building 12, Level 3, Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
| | - K Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia Intensive Care Unit, Level 2, Liverpool Hospital, Elizabeth St & Goulburn St, Liverpool NSW 2170, Australia
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Todd A, Husband A, Andrew I, Pearson SA, Lindsey L, Holmes H. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care 2016; 7:113-121. [DOI: 10.1136/bmjspcare-2015-000941] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/09/2015] [Accepted: 11/25/2015] [Indexed: 12/20/2022]
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Domingues D, Carneiro R, Costa I, Monteiro C, Shvetz Y, Barbosa AC, Azevedo P. Therapeutic futility in cancer patients at the time of palliative care transition: An analysis with a modified version of the Medication Appropriateness Index. Palliat Med 2015; 29:643-51. [PMID: 25701662 DOI: 10.1177/0269216315573687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative Care professionals are often confronted with therapeutic futility, consisting in inappropriate strategies that do not add any advantage to the patient and may actually increase adverse events. Scientific literature concerning this issue is lacking. This article is one of the first to study therapeutic futility specifically at the time of transition to the palliative care setting. AIM To study the phenomenon of pharmacologic therapeutic futility at the time of transition of a cancer patient to palliative care. DESIGN The pharmacological prescriptions at the time of the first appointment at an oncological palliative care unit during a time period of 2 months were prospectively collected and characterized using the Medication Appropriateness Index. PARTICIPANTS The sample comprised 71 patients with a mean age of 68.2 years. RESULTS The most common pharmacological groups were analgesics (n = 121; 19.2%), psychoactive drugs (n = 89; 14.1%), and antihypertensives (n = 51; 8.1%). A total of 61 patients (85.9%) consumed 5 drugs or more at the time of the first appointment. The mean number of daily medications decreased significantly after the palliative care team intervention, from 7.15 to 5.73 (p < 0.05). The principal causes of inappropriateness were absence of indication for the drug (23.0% "inappropriate"), the drugs' adverse interactions (11.1%), and inadequate dosage (9.9%). After the first consultation in the palliative care setting, 28.2% of the drugs were suspended. CONCLUSION This article tried to evaluate the main causes of therapeutic futility at the palliative care transition. The principal causes of inappropriateness were absence of clinical indication, clinically significant drug-disease/comorbidity interactions, and incorrect dosage/posology.
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Affiliation(s)
- Duarte Domingues
- Medical Oncology Service, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Rui Carneiro
- Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
| | - Isabel Costa
- Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
| | | | - Yulyia Shvetz
- Instituto Português de Oncologia Francisco Gentil, Porto, Portugal
| | - Ana C Barbosa
- Unidade de Saúde Familiar de Vale de Vez, Viana do Castelo, Portugal
| | - Pedro Azevedo
- Unidade de Saúde Familiar de Vale de Vez, Viana do Castelo, Portugal
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LeBlanc TW, McNeil MJ, Kamal AH, Currow DC, Abernethy AP. Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol 2015; 16:e333-41. [DOI: 10.1016/s1470-2045(15)00080-7] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Russell BJ, Rowett D, Abernethy AP, Currow DC. Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications. Intern Med J 2015; 44:177-84. [PMID: 24341863 DOI: 10.1111/imj.12340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/05/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects. AIM To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications. METHODS A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden. RESULTS Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile. CONCLUSIONS Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.
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Affiliation(s)
- B J Russell
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Inappropriate prescribing in patients accessing specialist palliative day care services. Int J Clin Pharm 2015; 36:535-43. [PMID: 24659040 DOI: 10.1007/s11096-014-9932-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 03/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND For patients accessing specialist palliative care day services, medication is prescribed routinely to manage acute symptoms, treat long-term conditions or prevent adverse events associated with these conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Consequently, the risk of these patients developing drug-related toxicities through drug–drug interactions is exacerbated. Medication use in this group should, therefore, be evaluated regularly to align with achievable therapeutic outcomes considering remaining life expectancy. OBJECTIVE To (1) assess the prevalence of inappropriate medication use; (2) identify potential drug–drug interactions; and, (3) determine how many potential drug– drug interactions could be prevented by discontinuing inappropriate medication. SETTING A specialist tertiary care palliative care centre in Northern England serving a population of 330,000. MAIN OUTCOME MEASURE Prescribing of inappropriate medication. METHOD Medication histories for patients accessing a specialist palliative day care centre were established and a modified Delphi method was used to reach consensus of medication appropriateness. The Delphi method utilized a framework considering the following factors: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Potential drug interactions were established using drug interaction recognition software and categorised by their ability to cause harm. RESULTS A total number of 132 patients were assessed during the study period who were prescribed 1,532 (mean = 12/patient) medications; 238 (16 %) were considered inappropriate in the context of limited life expectancy. The most common class of medications considered inappropriate were the statins, observed in 35 (27 %) patients. A total of 267 potential drug–drug interactions were identified; 112 were clinically significant and 155 were not considered clinically significant. Discontinuation of inappropriate medication would reduce the total number of medications taken to 1,294 (mean = 10/patient) and prevent 31 clinically significant potential drug–drug interactions. CONCLUSION Patients accessing specialist palliative day care services take many inappropriate medications. These medications not only increase the pharmacotherapeutic burden for the patient but they also contribute to potential drug–drug interactions. These patients should have their medication reviewed in the context of life limiting illness aligned with achievable therapeutic outcomes.
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