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Wollney EN, Armstrong MJ, Hampton CN, McCall-Junkin P, Bedenfield N, Fisher CL, Bylund CL. Triadic Communication in Medical Encounters Including Individuals With Dementia: A Scoping Review. Alzheimer Dis Assoc Disord 2024; 38:213-225. [PMID: 38812448 DOI: 10.1097/wad.0000000000000626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/02/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE The overall goal of this review was to identify what is known about triadic (clinician-patient-caregiver) communication in mild cognitive impairment (MCI) and dementia care settings throughout the care continuum. METHODS Using a structured search, we conducted a systematic scoping review of relevant published journal articles across 5 databases. Study titles/abstracts and selected full-text articles were screened by 2 investigators in Covidence systematic review software. Articles were excluded if they were not about clinical communication, focused only on caregiver-patient communication or communication in residential care, were interventional, lacked empirical data, or were not in English. Extracted data were documented using Google Forms. RESULTS The study team screened 3426 article titles and abstracts and 112 full-text articles. Forty-four articles were included in the final review. Results were categorized by 3 communication scenarios: diagnostic communication (n=22), general communication (n=16), and advanced care planning communication (n=6). CONCLUSIONS AND RELEVANCE Across the included articles, the conceptualization and assessment of communication lacked homogeneity. Future directions include addressing these research gaps, establishing recommendations for clinicians to effectively communicate with individuals with dementia and caregivers, and creating and testing communication skills trainings for caregivers/family members, clinicians, and/or individuals with dementia to facilitate effective communication.
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Affiliation(s)
- Easton N Wollney
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL
| | - Melissa J Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL
| | - Chelsea N Hampton
- Department of Advertising, College of Journalism and Communications, University of Florida, Gainesville, FL
| | - Patti McCall-Junkin
- Academic and Research Consulting Services, George A. Smathers Libraries, University of Florida, Gainesville, FL
| | - Noheli Bedenfield
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL
| | - Carla L Fisher
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL
| | - Carma L Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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Gréaux M, Moro MF, Kamenov K, Russell AM, Barrett D, Cieza A. Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services. Int J Equity Health 2023; 22:236. [PMID: 37957602 PMCID: PMC10644565 DOI: 10.1186/s12939-023-02035-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion. METHODS We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article. RESULTS Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities. CONCLUSION Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.
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Affiliation(s)
- Mélanie Gréaux
- Faculty of Education, University of Cambridge, Cambridge, UK.
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Tsunawaki S, Abe M, DeJonckheere M, Cigolle CT, Philips KK, Rubinstein EB, Matsuda M, Fetters MD, Inoue M. Primary care physicians' perspectives and challenges on managing multimorbidity for patients with dementia: a Japan-Michigan qualitative comparative study. BMC PRIMARY CARE 2023; 24:132. [PMID: 37370035 DOI: 10.1186/s12875-023-02088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Multimorbidity management can be extremely challenging in patients with dementia. This study aimed to elucidate the approaches of primary care physicians in Japan and the United States (US) in managing multimorbidity for patients with dementia and discuss the challenges involved. METHODS This qualitative study was conducted through one-on-one semi-structured interviews among primary care physicians, 24 each from Japan and Michigan, US. Thematic and content analyses were performed to explore similarities and differences among each country's data. RESULTS Primary care physicians in Japan and Michigan applied a relaxed adherence to the guidelines for patients' chronic conditions. Common challenges were the suboptimal consultation time, the insufficient number or ability of care-coordinating professionals, patients' conditions such as difficulties with self-management, living alone, behavioral issues, and refusal of care support. Unique challenges in Japan were free-access medical systems and not being sure about the patients' will in end-of-life care. In Michigan, physicians faced challenges in distance and lack of transportation between clinics and patients' homes and in cases where patients lacked the financial ability to acquire good care. CONCLUSIONS To improve the quality of care for patients with multimorbidity and dementia, physicians would benefit from optimal time and compensation allocated for this patient group, guidelines for chronic conditions to include information regarding changing priority for older adults with dementia, and the close collaboration of medical and social care and community resources with support of skilled care-coordinating professionals.
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Affiliation(s)
- Shinji Tsunawaki
- Omaezaki Family Medicine Center, Omaezaki, Shizuoka, Japan
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
| | - Michiko Abe
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | | | - Christine T Cigolle
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System (VAAAHS) Geriatric Research, Ann Arbor, MI, USA
| | - Kristin K Philips
- Education and Clinical Center (GRECC), VA Ann Arbor Healthcare System (VAAAHS) Geriatric Research, Ann Arbor, MI, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, ND, USA
| | - Masakazu Matsuda
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan
- Kikugawa Family Medicine Center, Kikugawa, Shizuoka, Japan
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
- The School of Health Humanities, Peking University Health Science Center, Beijing, China
| | - Machiko Inoue
- Shizuoka Family Medicine Program, Shizuoka, Hamamatsu, Japan.
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
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Vordenberg SE, Weir KR, Jansen J, Todd A, Schoenborn N, Scherer AM. Harm and Medication-Type Impact Agreement with Hypothetical Deprescribing Recommendations: a Vignette-Based Experiment with Older Adults Across Four Countries. J Gen Intern Med 2023; 38:1439-1448. [PMID: 36376636 PMCID: PMC10160278 DOI: 10.1007/s11606-022-07850-5] [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: 05/16/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about what factors are important to older adults when deciding whether to agree with a recommendation to deprescribe. OBJECTIVE To explore the extent to which medication type and rationale for potential discontinuation influence older adults' acceptance of deprescribing. DESIGN Cross-sectional 2 (drug: lansoprazole - treat indigestion; simvastatin - prevent cardiovascular disease) by 3 (deprescribing rationale: lack of benefit; potential for harm; both) experimental design. PARTICIPANTS Online panelists aged ≥65 years from Australia, the Netherlands, the United Kingdom, and the United States INTERVENTIONS: Participants were presented with a hypothetical patient experiencing polypharmacy whose PCP discussed stopping a medication. We randomized participants to receive one of six vignettes. MAIN MEASURES We measured agreement with deprescribing (6-point Likert scale, "Strongly disagree (1)" and "Strongly agree (6)") for the hypothetical patient as the primary outcome. We also measured participants' personality traits, perceptions of risk and uncertainty, and attitudes towards polypharmacy and deprescribing. KEY RESULTS Among 5311 participants (93.3% completion rate), the mean (M) agreement with deprescribing for the hypothetical patient was 4.71 (95% confidence interval (CI): 4.67, 4.75). Participants reported higher agreement with stopping lansoprazole (n=2656) (M=4.90, 95% CI: 4.85, 4.95) compared to simvastatin (n=2655) (M=4.53, 95% CI: 4.47, 4.58), P<.001. Participants who received the combination rationale (n=1786) reported higher agreement with deprescribing (M=4.83, 95% CI: 4.76, 4.89) compared to those who received the rationales on lack of benefit (n=1755) (M=4.66, 95% CI: 4.60, 4.73) or potential for harm (n=1770) (M=4.65, 95% CI 4.58, 4.72). In adjusted regression analyses (n=5062), participants with a higher desire to engage in health promotion behaviors (b=0.08, 95% CI 0.02, 0.13) or need for certainty (b=0.12, 95% CI 0.04, 0.20) reported higher agreement with deprescribing. CONCLUSIONS Older adults across four countries were accepting of deprescribing in the setting of polypharmacy. The medication type and rationale for discontinuation were important factors in the decision-making process. TRIAL REGISTRATION ClinicalTrials.gov , NCT04676282, https://clinicaltrials.gov/ct2/show/NCT04676282?term=vordenberg&draw=2&rank=1.
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Affiliation(s)
- Sarah E Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St, 3563 NUB, Ann Arbor, MI, 48109, USA.
| | - Kristie Rebecca Weir
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Adam Todd
- Newcastle University School of Pharmacy, Newcastle upon Tyne, UK
| | | | - Aaron M Scherer
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Green AR, Aschmann H, Boyd CM, Schoenborn N. Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey. J Am Geriatr Soc 2022; 70:2895-2904. [PMID: 35661991 PMCID: PMC9588518 DOI: 10.1111/jgs.17917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/04/2022] [Accepted: 05/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications. METHODS A cross-sectional survey was conducted from March-April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities. RESULTS Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02-2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05-2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39-1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48-0.91]). CONCLUSIONS Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.
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Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Hélène Aschmann
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichZurichSwitzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of Health Policy and ManagementJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Nancy Schoenborn
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Thompson W, Jarbøl D, Nielsen JB, Haastrup P, Pedersen LB. GP preferences for discussing statin deprescribing: a discrete choice experiment. Fam Pract 2022; 39:26-31. [PMID: 34268565 DOI: 10.1093/fampra/cmab075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deprescribing (planned, supervised discontinuation) of statins may be considered in some older persons. This should be carefully discussed between patients and GPs. METHODS We examined GPs' preferences for discussing statin deprescribing by conducting a discrete choice experiment (DCE) sent to a stratified random sample of 500 Danish GPs. Attributes were discussion topics (goals of therapy, evidence on statin use in older persons, adverse effects, uncertainty), and levels were the depth of the discussion topics (none, brief, detailed). We used mixed logistic regression for analysis. RESULTS A total of 90 GPs (mean age 48, 54% female, mean 11 years in practice) completed the DCE. There was substantial variability in which topics GPs felt were most important to discuss; however, GPs generally preferred a brief discussion of topics to detailed ones. The most important discussion topic appeared to be goals of therapy. GPs felt a brief discussion of evidence was important but not a detailed one, while adverse effects and uncertainty were felt to be less important to discuss. CONCLUSION GPs prefer brief discussions on a range of topics when discussing statin deprescribing but have differing views on which topics are most important. For deprescribing communication tools to be useful to GPs in clinical practice, they may need to focus on brief coverage of the range of relevant topics. Future work should evaluate patient preferences, and opportunities for education and training for GPs on deprescribing communication.
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Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Hospital Pharmacy Fyn, Odense University Hospital, Odense, Denmark
| | - Dorte Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Peter Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Line Bjørnskov Pedersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Danish Centre for Health Economics (DaCHE), Department of Public Health, University of Southern Denmark, Odense, Denmark
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Mehawej J, Saczynski J, Abu HO, Gagnier M, Bamgbade BA, Lessard D, Trymbulak K, Saleeba C, Kiefe CI, Goldberg RJ, McManus DD. Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation. Can Geriatr J 2021; 24:174-183. [PMID: 34484500 PMCID: PMC8390325 DOI: 10.5770/cgj.24.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF). METHODS We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM. RESULTS A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups. CONCLUSIONS A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.
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Affiliation(s)
- Jordy Mehawej
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Hawa O. Abu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marc Gagnier
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Connor Saleeba
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Motter FR, Cantuaria NM, Lopes LC. Healthcare professionals' knowledge, attitudes and practices toward deprescribing: a protocol of cross-sectional study (Desmedica Study-Brazil). BMJ Open 2021; 11:e044312. [PMID: 34341031 PMCID: PMC8330586 DOI: 10.1136/bmjopen-2020-044312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit. It is an activity that should be a normal part of care/the prescribing cycle. Although now broadly recognised, there are still challenges in its effective implementation. OBJECTIVES To develop and validate an instrument to measure Brazilian healthcare professionals' knowledge, attitudes and practices towards deprescribing. METHODS This study will include the following steps: (1) development of the preliminary instrument; (2) content validation; (3) pilot study; (4) evaluation of psychometric characteristics. After the elaboration of items of the instrument through the literature review, we will use a hybrid Delphi method to develop and establish the content validity of the instrument. Further, a pilot survey will be performed with 30 healthcare professionals. Finally, for the evaluation of psychometric characteristics, a cross-sectional study will be accomplished with a representative sample of different healthcare professionals from different Brazilian states using respondent-driven sampling. Exploratory factor analysis and confirmatory factor analysis will be performed. For assessing the model fit, we will use the ratio of χ2 and df (χ2/df), comparative fit index, the goodness of fit index and root mean square error of approximation. In addition, the reliability of the instrument will be estimated by test-retest reproducibility and Cronbach's alpha coefficient (α). ETHICS AND DISSEMINATION The Ethics Committee for Research at the University of Sorocaba (ethics approval number: 3.848.916) approved the study. Study findings will be circulated to healthcare professionals and scientists in the field through publication in peer-reviewed journals and conference presentations.
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Affiliation(s)
- Fabiane Raquel Motter
- Graduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
| | | | - Luciane Cruz Lopes
- Graduate Program in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
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Chronic Care, Dementia Care Management, and Financial Considerations. J Am Med Dir Assoc 2021; 22:1371-1376. [PMID: 34081893 DOI: 10.1016/j.jamda.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022]
Abstract
The needs of persons living with Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD) are challenged by tremendous complexity impacting both care delivery and financing. Most persons living with dementia (PLWD) also suffer from other chronic medical or mental health conditions, which further burden quality of life and function. In addition to difficult treatment choices, optimal dementia care models likely involve people and services that are not typical pieces of the health care delivery system but are all critical partners-care partners, social workers, and community services, to name a few. More than 200 models of dementia care have demonstrated some efficacy. However, these successful interventions that might address much of the care needed by PLWD are uninsured in the United States, where insurance coverage has focused on acute care needs. This poses great difficulties for both care provision and care financing. In this article, we review these 3 key challenges: dementia care for those with chronic comorbid disease; care models that require people who are not typical providers in traditional care delivery systems; and the mandate to provide high-quality care that is currently not funded by usual health care insurance. We propose promising next steps that could substantially improve the lives of PLWD and the lives of their care partners, and highlight some of the many research questions that remain.
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Green AR, Aschmann H, Boyd CM, Schoenborn N. Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults. JAMA Netw Open 2021; 4:e212633. [PMID: 33818621 PMCID: PMC8022217 DOI: 10.1001/jamanetworkopen.2021.2633] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE How clinicians communicate about deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, may be associated with the extent to which older adults are willing to do it. OBJECTIVE To examine older adults' preferences regarding different rationales a clinician may use to explain why a patient should stop an unnecessary or potentially harmful medication. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey study was conducted from March 25 to April 19, 2020, among a nationally representative, probability-based online survey panel (KnowledgePanel). KnowledgePanel members aged 65 years and older were recruited by random digit dialing and address-based sampling. Data were analyzed from May 4 to July 8, 2020. EXPOSURES The survey presented 2 vignettes involving hypothetical older adults. One described a statin being used for primary prevention by a person with functional impairment and polypharmacy. The second described a sedative-hypnotic, such as zolpidem, being used for insomnia by a person with good functional status. MAIN OUTCOMES AND MEASURES After each vignette, participants expressed preferences using a best-worst scaling method for 7 different phrases a clinician may use to explain why they should reduce or stop the medication. Conditional logistic regression was used to quantify respondents' relative preferences. RESULTS A total of 1193 KnowledgePanel members were invited, and 835 respondents (70.0%) completed the survey. The mean (SD) age was 73 (6) years, 414 (49.6%) were women, and 671 (80.4%) self-identified as White individuals. A total of 496 respondents (59.8%) had ever used a statin, and 124 respondents (14.9%) had ever used a sedative-hypnotic. For both medications, the most preferred phrase to explain deprescribing focused on the risk of side effects. For statins, this phrase was 5.8-fold (95% CI, 5.3-6.3) more preferred than the least preferred option, which focused on the effort (treatment burden) involved in taking the medicine. For sedative-hypnotics, the phrase about side effects was 8.6-fold (95% CI, 7.9-9.5) more preferred over the least preferred option, "This medicine is unlikely to help you function better." CONCLUSIONS AND RELEVANCE These findings suggest that among older adults, the most preferred rationale for deprescribing both preventive and symptom-relief medicines focused on the risk of side effects. These results could be used to inform clinical practice and improve effective communications around deprescribing in older adults.
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Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hélène Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Nancy Schoenborn
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.
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Affiliation(s)
- Vassiliki Pravodelov
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, Robinson 2, Boston, MA 02118, USA; Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA.
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