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Hürlimann O, Alers D, Hauri N, Leist P, Schneider C, Bolt L, Rodondi N, Aubert CE. Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives. BMC Geriatr 2024; 24:396. [PMID: 38704540 PMCID: PMC11069272 DOI: 10.1186/s12877-024-05027-9] [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: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects. METHODS We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences. RESULTS The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes. CONCLUSION The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.
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Affiliation(s)
- Orlando Hürlimann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
| | - Daphne Alers
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
| | - Noël Hauri
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
| | - Pascal Leist
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
| | - Claudio Schneider
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
| | - Lucy Bolt
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Carole E Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Anna-Von-Krauchthal Weg 7, Bern, 3010, Switzerland.
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
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Kaambwa B, Woods TJ, Natsky A, Bulamu N, Mpundu-Kaambwa C, Loffler KA, Sweetman A, Catcheside PG, Reynolds AC, Adams R, Eckert DJ. Content Comparison of Quality-of-Life Instruments Used in Economic Evaluations of Sleep Disorder Interventions: A Systematic Review. PHARMACOECONOMICS 2024; 42:507-526. [PMID: 38340220 PMCID: PMC11039546 DOI: 10.1007/s40273-023-01349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Assessment of quality of life (QoL) in people living with sleep disorders using questionnaires is necessary to compare intervention benefits. Knowledge of the content and concepts covered by specific QoL instruments is essential to determine which instruments are best suited for conducting economic evaluations of sleep-related interventions. OBJECTIVES This review aims to identify the QoL instruments that have been applied in economic evaluations of sleep disorder interventions and compare their conceptual overlap and content coverage using the framework of the International Classification of Functioning, Disability and Health (ICF). METHODS A systematic review of full economic evaluations in sleep published in peer-reviewed journals from conception to 30 May, 2023 was conducted. MEDLINE, PsychInfo, ProQuest, Cochrane, Scopus, CINAHL, Web of Science and Emcare were searched for eligible studies. Studies incorporating either generic or sleep-specific QoL instruments as the primary or secondary measures of effectiveness within a full economic evaluation were included. Quality appraisal against the JBI Critical Appraisal Checklist for Economic Evaluations and EURONHEED checklists and mapping of QoL items to ICF categories were performed by two reviewers, with a third helping settle any potential differences. RESULTS Sixteen instruments were identified as having been used in sleep health economic evaluations. The EQ-5D-3L, Epworth Sleepiness Scale, and Insomnia Severity Index were the most widely used, but the latter two are predominantly diagnostic tools and not specifically designed to guide economic evaluations. Other instruments with broader ICF content coverage have been least used, and these include the Sleep Apnea Quality of Life Index, Functional Outcomes of Sleep Questionnaire, 15 Dimensions, Short-Form 6 Dimensions, 12-item Short Form Survey, 36-item Short Form Survey and the GRID Hamilton Rating Scale for Depression. CONCLUSIONS This study provides an overview of current QoL instruments used in economic evaluations of sleep with respect to their content coverage. A combination of generic and sleep-specific instruments with broader ICF content coverage is recommended for such evaluations.
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Affiliation(s)
- Billingsley Kaambwa
- Health Economics Unit, College of Medicine and Public Health, Flinders University, Health Sciences Building, Sturt Road, Bedford Park, SA, 5042, Australia.
| | - Taylor-Jade Woods
- Health Economics Unit, College of Medicine and Public Health, Flinders University, Health Sciences Building, Sturt Road, Bedford Park, SA, 5042, Australia
| | - Andrea Natsky
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Norma Bulamu
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Christine Mpundu-Kaambwa
- Health and Social Care Economics Group, Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Kelly A Loffler
- Health Data and Clinical Trials, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
| | - Alexander Sweetman
- Flinders Health and Medical Research Institute (Sleep Health)/formerly Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Peter G Catcheside
- Flinders Health and Medical Research Institute (Sleep Health)/formerly Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Amy C Reynolds
- Flinders Health and Medical Research Institute (Sleep Health)/formerly Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Robert Adams
- Flinders Health and Medical Research Institute (Sleep Health)/formerly Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute (Sleep Health)/formerly Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
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Baldursdottir K, Asgeirsdottir TL, Olafsdottir T. How sensitive is the compensating income variation to severity and adaptation? ECONOMICS AND HUMAN BIOLOGY 2023; 49:101213. [PMID: 36608357 DOI: 10.1016/j.ehb.2022.101213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/17/2022] [Accepted: 12/13/2022] [Indexed: 05/08/2023]
Abstract
Knowing the monetary value individuals place on health is essential in tackling resource allocation between health and other uses. However, health conditions vary greatly, not only with respect to main characteristics but also by severity and duration. We apply the compensating income variation (CIV) method to data from the Swiss Household Panel, years 2004-2019, to explore the sensitivity of CIV estimates to severity and adaptation across five different health conditions: headaches, back problems, sleep problems, fatigue, and chronic illness. Accounting for income endogeneity in the life-satisfaction equations and adjusting for individual random effects, we found the CIV estimates to range from $3184 for moderate headaches (women) to $100,066 for severe fatigue (men). Individuals with severe conditions needed to be compensated about three times more than those suffering less. Across the five conditions with two severity levels explored for adaptation, individuals only adapted to moderate headaches and severe sleep problems. In conclusion, not only does the value of health conditions vary greatly, but within each health condition its value on average triples when severe condition is reported as opposed to moderate. Adaptation plays a minor role in CIV estimates for the five health conditions explored.
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Affiliation(s)
| | | | - Thorhildur Olafsdottir
- Faculty of Business Administration, University of Iceland, Oddi v/Sturlugotu, 101 Reykjavik, Iceland.
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Ernstsen L, Zotcheva E, Sui X, Engstrøm M, Martínez-Velilla N, Bjerkeset O, Bjorvatn B, Havnen A. Association Between Cardiorespiratory Fitness and Incident Purchase of Hypnotic Drugs in Adults: The HUNT Study. Mayo Clin Proc 2023; 98:229-238. [PMID: 36244824 DOI: 10.1016/j.mayocp.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess whether cardiorespiratory fitness (CRF) is associated with first purchase of a prescribed hypnotic drug in the adult population. METHODS A total of 34,357 adult participants (53.9% women) with a mean age of 51.5 years (SD 15.6 years) from the third Trøndelag Health Study (HUNT) of 2006 to 2008 were observed until January 1, 2018. Cardiorespiratory fitness was estimated from a validated nonexercise algorithm. Data on first hypnotics prescription were obtained through linkage to the National Norwegian Prescription Database. Cox regression with 95% CIs was used to estimate hazard ratios (HRs). RESULTS After 304,899 person-years of follow-up, 5791 participants had their first registered purchase of prescribed hypnotics, corresponding to an incidence rate of 1.90 per 100 person-years. Each 1-metabolic equivalent of task increase in CRF was significantly associated with 5% (HR, 0.95; 95% CI, 0.91 to 0.99; P=.02) and 4% (HR, 0.96; 95% CI, 0.92 to 1.00; P=.046) risk reduction for incident use of hypnotics in men and women, respectively. When CRF was categorized into tertiles with lowest CRF as the reference group, reduced risk was 13% (HR, 0.87; 95% CI, 0.79 to 0.96; P=.006) and 15% (HR, 0.85; 95% CI, 0.77 to 0.95; P=.003) for men in the intermediate and highest CRF category, respectively. In women with highest CRF, the reduced risk was 5% (HR, 0.95; 95% CI, 0.87 to 1.03; P=.22). CONCLUSION Cardiorespiratory fitness in adulthood is associated with incident purchase of prescription medication commonly used for sleep problems. These findings suggest that fitness should be considered a target for preventing sleep problems in adults.
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Affiliation(s)
- Linda Ernstsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Norway.
| | - Ekaterina Zotcheva
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Norway; Department of Physical Health and Aging, Norwegian Institute of Public Health, Norway
| | - Xuemei Sui
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia
| | - Morten Engstrøm
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Norway; Department of Neurology and Clinical Neurophysiology, St. Olavs Hospital, Trondheim University Hospital, Norway
| | - Nicolás Martínez-Velilla
- Geriatrics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN)-Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Ottar Bjerkeset
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Norway; Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| | - Bjørn Bjorvatn
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Audun Havnen
- Department of Psychology, Norwegian University of Science and Technology, Norway; Division of Psychiatry, St. Olavs Hospital, Trondheim University Hospital, Norway
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Ikeda S, Azuma MK, Fujimoto K, Shibahara H, Inoue S, Moline M, Ishii M, Mishima K. Cost-effectiveness analysis of lemborexant for treating insomnia in Japan: a model-based projection, incorporating the risk of falls, motor vehicle collisions, and workplace accidents. Psychol Med 2022; 52:2822-2834. [PMID: 35506334 PMCID: PMC9647554 DOI: 10.1017/s0033291722000356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 01/21/2022] [Accepted: 01/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Lemborexant has demonstrated statistically significant improvements in sleep onset and sleep maintenance compared with placebo and zolpidem tartrate extended release, measured both objectively using polysomnography and subjectively using sleep diaries, in the phase 3 clinical trial SUNRISE 1. This study evaluated the cost-effectiveness of lemborexant compared with suvorexant, zolpidem immediate release (IR), and untreated insomnia. METHODS A decision-tree model was developed for falls, motor vehicle collisions, and workplace accidents associated with insomnia and insomnia treatments from a Japanese healthcare perspective and with a 6-month time horizon. The model extracted subjective sleep onset latency treatment responses and disutility values for non-responders from SUNRISE 1. Cost-effectiveness was assessed using incremental cost per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were conducted to evaluate the impact of parameter uncertainty on the results. RESULTS In the base-case analysis, the mean estimated QALYs for lemborexant, suvorexant, zolpidem-IR, and untreated insomnia were 0.4220, 0.4204, 0.4113, and 0.4163, and expected medical costs were JPY 34 034, JPY 38 371, JPY 38 139, and JPY 15 383, respectively. Lemborexant saved JPY 4337 and JPY 4105 compared with suvorexant or zolpidem-IR, respectively, while conferring QALY benefits. The incremental cost-effectiveness ratio (ICER) of lemborexant compared with that of untreated insomnia was JPY 3 220 975 /QALY. Lemborexant was dominant over suvorexant and zolpidem-IR and was cost-effective when compared with untreated insomnia. Sensitivity analyses supported the results' robustness. CONCLUSIONS In a Japanese clinical practice setting, lemborexant may represent a better investment for treating insomnia in the healthcare system in Japan.
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Affiliation(s)
- Shunya Ikeda
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
| | | | | | - Hidetoshi Shibahara
- CRECON Medical Assessment Inc., Tokyo, Japan
- Graduate School of Health and Welfare, International University of Health and Welfare, Tokyo, Japan
| | | | | | | | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
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Kwon J, Squires H, Franklin M, Young T. Systematic review and critical methodological appraisal of community-based falls prevention economic models. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:33. [PMID: 35842721 PMCID: PMC9287934 DOI: 10.1186/s12962-022-00367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research. METHODS The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results. RESULTS 46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made. CONCLUSION Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Matthew Franklin
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA England UK
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Kwon J, Squires H, Franklin M, Lee Y, Young T. Economic models of community-based falls prevention: a systematic review with subsequent commissioning and methodological recommendations. BMC Health Serv Res 2022; 22:316. [PMID: 35255898 PMCID: PMC8902781 DOI: 10.1186/s12913-022-07647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Falls impose significant health and economic burdens among older populations, making their prevention a priority. Health economic models can inform whether the falls prevention intervention represents a cost-effective use of resources and/or meet additional objectives such as reducing social inequities of health. This study aims to conduct a systematic review (SR) of community-based falls prevention economic models to: (i) systematically identify such models; (ii) synthesise and critically appraise modelling methods/results; and (iii) formulate methodological and commissioning recommendations. Methods The SR followed PRISMA 2021 guideline, covering the period 2003–2020, 12 academic databases and grey literature. A study was included if it: targeted community-dwelling persons aged 60 and over and/or aged 50–59 at high falls risk; evaluated intervention(s) designed to reduce falls or fall-related injuries; against any comparator(s); reported outcomes of economic evaluation; used decision modelling; and had English full text. Extracted data fields were grouped by: (A) model and evaluation overview; (B) falls epidemiology features; (C) falls prevention intervention features; and (D) evaluation methods and outcomes. A checklist for falls prevention economic evaluations was used to assess reporting/methodological quality. Extracted fields were narratively synthesised and critically appraised to inform methodological and commissioning recommendations. The SR protocol is registered in the Prospective Register of Systematic Reviews (CRD42021232147). Results Forty-six models were identified. The most prevalent issue according to the checklist was non-incorporation of all-cause care costs. Based on general population, lifetime models conducting cost-utility analyses, seven interventions produced favourable ICERs relative to no intervention under the cost-effectiveness threshold of US$41,900 (£30,000) per QALY gained; of these, results for (1) combined multifactorial and environmental intervention, (2) physical activity promotion for women, and (3) targeted vitamin D supplementation were from validated models. Decision-makers should explore the transferability and reaches of interventions in their local settings. There was some evidence that exercise and home modification exacerbate existing social inequities of health. Sixteen methodological recommendations were formulated. Conclusion There is significant methodological heterogeneity across falls prevention models. This SR’s appraisals of modelling methods should facilitate the conceptualisation of future falls prevention models. Its synthesis of evaluation outcomes, though limited to published evidence, could inform commissioning. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07647-6.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England.
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
| | - Matthew Franklin
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
| | - Yujin Lee
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, England
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, S1 4DA, England
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Chen S, Xu Z, Li Y, Wang T, Yue Y, Hou Z, You L, Lu N, Yin Y, Liu X, Tan L, Ji H, Shi Y, Xin X, Jiang W, Yuan Y. Clinical Efficacy of the Chinese Herbal Medicine Shumian Capsule for Insomnia: A Randomized, Double-Blind, Placebo-Controlled Trial. Neuropsychiatr Dis Treat 2022; 18:669-679. [PMID: 35378821 PMCID: PMC8976492 DOI: 10.2147/ndt.s349427] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/09/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Shumian capsule (SMC) is a patent Chinese herbal medicine that can soothe the liver and relieves depression, quiet the spirit. Here, we aimed to investigate the efficacy of SMC for treating insomnia using both scales and polysomnography (PSG). PATIENTS AND METHODS A randomized, double-blind, placebo-controlled trial was performed. Twenty-six insomnia patients randomly received SMC (n = 11) or placebo (n = 15) for four weeks. Pittsburgh Sleep Quality Inventory (PSQI), Insomnia Severity Index (ISI), 9-items Patient Health Questionnaire (PHQ-9), 7-items Generalized Anxiety Disorder (GAD-7), 17-item Hamilton Depression Rating Scale (HAMD-17), and Hamilton Anxiety Rating Scale (HAMA) were applied at the baseline and the 2nd, 4th week after treatment. Treatment Emergent Symptom Scale was used to assess adverse reactions. We used PSG to record and analyze sleep features at baseline and after four weeks. RESULTS PSQI, ISI, PHQ-9, HAMD-17, and HAMA scores decreased significantly after SMC treatment. Also, the total sleep time, rapid-eye-movement (REM) sleep latency, stage 2 sleep, deep sleep, REM sleep, and sleep efficiency improved significantly after SMC treatment. In the placebo group, the only significant change was the decrease of PHQ-9 at week-2. Furthermore, both SMC and placebo reported no adverse events. CONCLUSION SMC could safely improve sleep quality with depression and anxiety remission in insomnia patients.
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Affiliation(s)
- Suzhen Chen
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Zhi Xu
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Yinghui Li
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Tianyu Wang
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Yingying Yue
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Zhenghua Hou
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Linlin You
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Na Lu
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Yingying Yin
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Xiaoyun Liu
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Liangliang Tan
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Houcheng Ji
- Department of Psychiatry, The Second People's Hospital of Jiangning District, Nanjing, People's Republic of China
| | - Yaoran Shi
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Xiaoyun Xin
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Wenhao Jiang
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Yonggui Yuan
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China.,Institute of Psychosomatics, School of Medicine, Southeast University, Nanjing, People's Republic of China
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9
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Kwon J, Lee Y, Young T, Squires H, Harris J. Qualitative research to inform economic modelling: a case study in older people's views on implementing the NICE falls prevention guideline. BMC Health Serv Res 2021; 21:1020. [PMID: 34583685 PMCID: PMC8479997 DOI: 10.1186/s12913-021-07056-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background High prevalence of falls among older persons makes falls prevention a public health priority. Yet community-based falls prevention face complexity in implementation and any commissioning strategy should be subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on community-based falls prevention and explore how the qualitative data can be used to inform commissioning strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield. Methods Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3) methodological and evaluative challenges for public health economic modelling. Results Two cross-component factors were identified: health motives of older persons; and professional competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups. The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy (including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic complexity; considering social determinants of health; and conducting equity analyses. Conclusions Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of quantitative models used to inform geriatric public health policies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07056-1.
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Affiliation(s)
- Joseph Kwon
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA.
| | - Yujin Lee
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, England, CV4 7AL
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
| | - Hazel Squires
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
| | - Janet Harris
- School of Health and Related Research, University of Sheffield, Regent Court (ScHARR), 30 Regent Street, Sheffield, England, S1 4DA
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10
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Darden M, Espie CA, Carl JR, Henry AL, Kanady JC, Krystal AD, Miller CB. Cost-effectiveness of digital cognitive behavioral therapy (Sleepio) for insomnia: a Markov simulation model in the United States. Sleep 2021; 44:5957088. [PMID: 33151330 DOI: 10.1093/sleep/zsaa223] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
STUDY OBJECTIVES To examine the cost-effectiveness and potential net monetary benefit (NMB) of a fully automated digital cognitive behavioral therapy (CBT) intervention for insomnia compared with no insomnia treatment in the United States (US). Similar relative comparisons were made for pharmacotherapy and clinician-delivered CBT (individual and group). METHODS We simulated a Markov model of 100,000 individuals using parameters calibrated from the literature including direct (treatment) and indirect costs (e.g. insomnia-related healthcare expenditure and lost workplace productivity). Health utility estimates were converted into quality-adjusted life years (QALYs) and one QALY was worth $50,000. Simulated individuals were randomized equally to one of five arms (digital CBT, pharmacotherapy, individual CBT, group CBT, or no insomnia treatment). Sensitivity was assessed by bootstrapping the calibrated parameters. Cost estimates were expressed in 2019 US dollars. RESULTS Digital CBT was cost beneficial when compared with no insomnia treatment and had a positive NMB of $681.06 (per individual over 6 months). Bootstrap sensitivity analysis demonstrated that the NMB was positive in 94.7% of simulations. Relative to other insomnia treatments, digital CBT was the most cost-effective treatment because it generated the smallest incremental cost-effectiveness ratio (-$3,124.73). CONCLUSIONS Digital CBT was the most cost-effective insomnia treatment followed by group CBT, pharmacotherapy, and individual CBT. It is financially prudent and beneficial from a societal perspective to utilize automated digital CBT to treat insomnia at a population scale.
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Affiliation(s)
- Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD
| | - Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Big Health Inc., London, UK.,Big Health Inc., San Francisco, CA
| | - Jenna R Carl
- Big Health Inc., London, UK.,Big Health Inc., San Francisco, CA
| | - Alasdair L Henry
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Big Health Inc., London, UK.,Big Health Inc., San Francisco, CA
| | | | - Andrew D Krystal
- Department of Psychiatry, School of Medicine, University of California San Francisco, San Francisco, CA.,Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Christopher B Miller
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Big Health Inc., London, UK.,Big Health Inc., San Francisco, CA
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11
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Economic evaluation of cognitive behavioural therapy for insomnia (CBT-I) for improving health outcomes in adult populations: A systematic review. Sleep Med Rev 2020; 54:101351. [DOI: 10.1016/j.smrv.2020.101351] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/10/2023]
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12
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Jalal Z, Cheema E, Hadi MA, Sharma P, Stewart D, Al Hamid A, Haque MS, Moore PV, Paudyal V. Pharmacists providing prescribing advice and education to healthcare professionals in community, primary care and outpatient settings. Hippokratia 2020. [DOI: 10.1002/14651858.cd013793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Zahraa Jalal
- School of Pharmacy; University of Birmingham; Birmingham UK
| | - Ejaz Cheema
- Department of Pharmacy Practice; University of Birmingham; Birmingham UK
| | | | - Pawana Sharma
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Derek Stewart
- Qatar University Health College of Pharmacy; Qatar University; Doha Qatar
| | - Abdullah Al Hamid
- Pharmacy; General Directorate of Health Affairs; Najran Saudi Arabia
| | - Mohammed S Haque
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Patrick V Moore
- Institute of Applied Health Research; University of Birmingham; Birmingham UK
| | - Vibhu Paudyal
- School of Pharmacy; University of Birmingham; Birmingham UK
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13
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Desjardins S, Lapierre S, Vasiliadis HM, Hudon C. Evaluation of the Effects of an Intervention Intended to Optimize the Sleep Environment Among the Elderly: An Exploratory Study. Clin Interv Aging 2020; 15:2117-2127. [PMID: 33204077 PMCID: PMC7665518 DOI: 10.2147/cia.s277252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/07/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose The objective of this exploratory study was to evaluate the effects of a brief intervention intended to optimize the sleep environment in older people living in the community and to examine the way these effects change over time. Methods The sample was made up of 44 participants (19 men and 25 women) aged 65-85 years, with a mean age of 71.4. The intervention consisted in a group training session that covered the reasons for and ways to ("why" and "how") optimize a sleep environment. It comprises six themes: air quality and odors, luminosity, noises and sounds, comfort of the mattress, comfort of the pillow, and temperature. Participants completed a set of questionnaires before the intervention, and one month and four months later. Results Four months after the intervention, the replies to the questionnaires showed that the participants experienced reduced severity of insomnia, sleep latency and anxiety. The subjective quality of the participants' sleep along with their sleep efficacy also increased significantly during the same period. Conclusion A brief intervention intended to optimize the sleep environment appears promising as an addition or alternative to the two other sleep improvement options generally offered to older people: medication and cognitive behavioral therapy.
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Affiliation(s)
- Sophie Desjardins
- Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Sylvie Lapierre
- Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Helen-Maria Vasiliadis
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Carol Hudon
- School of Psychology, Université Laval, Québec, Québec, Canada
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14
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Turner JP, Sanyal C, Martin P, Tannenbaum C. Economic Evaluation of Sedative Deprescribing in Older Adults by Community Pharmacists. J Gerontol A Biol Sci Med Sci 2020; 76:1061-1067. [DOI: 10.1093/gerona/glaa180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Indexed: 01/30/2023] Open
Abstract
Abstract
Background
Sedative use in older adults increases the risk of falls, fractures, and hospitalizations. The D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), pragmatic randomized clinical trial demonstrated that community-based, pharmacist-led education delivered simultaneously to older adults and their primary care providers reduce the use of sedatives by 43% over 6 months. However, the associated health benefits and cost savings have yet to be described. This study evaluates the cost-effectiveness of the D-PRESCRIBE intervention compared to usual care for reducing the use of potentially inappropriate sedatives among older adults.
Methods
A cost-utility analysis from the public health care perspective of Canada estimated the costs and quality-adjusted life-years (QALYs) associated with the D-PRESCRIBE intervention compared to usual care over a 1-year time horizon. Transition probabilities, intervention effectiveness, utility, and costs were derived from the literature. Probabilistic analyses were performed using a decision tree and Markov model to estimate the incremental cost-effectiveness ratio.
Results
Compared to usual care, pharmacist-led deprescribing is less costly (−$1392.05 CAD) and more effective (0.0769 QALYs). Using common willingness-to-pay (WTP) thresholds of $50 000 and $100 000, D-PRESCRIBE was the optimal strategy. Scenario analysis indicated the cost-effectiveness of D-PRESCRIBE is sensitive to the rate of deprescribing.
Conclusions
Community pharmacist-led deprescribing of sedatives is cost-effective, leading to greater quality-of-life and harm reduction among older adults. As the pharmacist’s scope of practice expands, consideration should be given to interprofessional models of remuneration for quality prescribing and deprescribing services.
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Affiliation(s)
- Justin P Turner
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | | | - Philippe Martin
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | - Cara Tannenbaum
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Québec, Canada
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15
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Shaw J, Murphy AL, Turner JP, Gardner DM, Silvius JL, Bouck Z, Gordon D, Tannenbaum C. Policies for Deprescribing: An International Scan of Intended and Unintended Outcomes of Limiting Sedative-Hypnotic Use in Community-Dwelling Older Adults. ACTA ACUST UNITED AC 2020; 14:39-51. [PMID: 31322113 PMCID: PMC7008681 DOI: 10.12927/hcpol.2019.25857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.
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Affiliation(s)
- James Shaw
- Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Andrea L Murphy
- Associate Professor, College of Pharmacy, Dalhousie University, Halifax, NS
| | - Justin P Turner
- Graduate Student, Centre de Recherche Institut Universitaire de Gériatrie de Montréal, Montreal, QC
| | - David M Gardner
- Professor, Department of Psychiatry, Dalhousie University, Halifax, NS
| | - James L Silvius
- Co-Director, Canadian Deprescribing Network; Associate Professor, Department of Medicine, University of Calgary, Calgary, AB
| | - Zachary Bouck
- Biostatistician, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Dara Gordon
- Research Coordinator, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Cara Tannenbaum
- Co-Director, Canadian Deprescribing Network; Professor, Faculties of Medicine and Pharmacy Université de Montréal, Montreal, QC
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16
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Wickwire EM, Vadlamani A, Tom SE, Johnson AM, Scharf SM, Albrecht JS. Economic aspects of insomnia medication treatment among Medicare beneficiaries. Sleep 2020; 43:5550317. [PMID: 31418027 DOI: 10.1093/sleep/zsz192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/17/2019] [Indexed: 01/07/2023] Open
Abstract
STUDY OBJECTIVES To examine economic aspects of insomnia and insomnia medication treatment among a nationally representative sample of older adult Medicare beneficiaries. METHODS Using a random 5% sample of Medicare administrative data (2006-2013), insomnia was defined using International Classification of Disease, Version 9, Clinical Modification diagnostic codes. Treatment was operationalized as one or more prescription fills for an US Food and Drug Administration (FDA)-approved insomnia medication following diagnosis, in previously untreated individuals. To evaluate the economic impact of insomnia treatment on healthcare utilization (HCU) and costs in the year following insomnia diagnosis, a difference-in-differences approach was implemented using generalized linear models. RESULTS A total of 23 079 beneficiaries with insomnia (M age = 71.7 years) were included. Of these, 5154 (22%) received one or more fills for an FDA-approved insomnia medication following insomnia diagnosis. For both treated and untreated individuals, HCU and costs increased during the 12 months prior to diagnosis. Insomnia treatment was associated with significantly increased emergency department visits and prescription fills in the year following insomnia diagnosis. After accounting for pre-diagnosis differences between groups, no significant differences in pre- to post-diagnosis costs were observed between treated and untreated individuals. CONCLUSIONS These results advance previous research into economics of insomnia disorder by evaluating the impact of medication treatment and highlighting important differences between treated and untreated individuals. Future studies should seek to understand why some individuals diagnosed with insomnia receive treatment but others do not, to identify clinically meaningful clusters of older adults with insomnia, and to explore the economic impact of insomnia and insomnia treatment among subgroups of individuals with insomnia, such as those with cardiovascular diseases, mood disorders, and neurodegenerative disease.
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Affiliation(s)
- Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD.,Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Aparna Vadlamani
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Sarah E Tom
- Department of Neurology and Epidemiology, Columbia University, New York, NY
| | - Abree M Johnson
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Steven M Scharf
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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17
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Hassinger AB, Bletnisky N, Dudekula R, El-Solh AA. Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert Opin Pharmacother 2020; 21:1035-1043. [PMID: 32202451 DOI: 10.1080/14656566.2020.1743265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic insomnia, whether it is primary or in combination with another medical or psychiatric disorder, is a prevalent condition associated with significant morbidity, reduced productivity, increased risk of accidents, and poor quality of life. Pharmacologic and behavioral treatments have equivalent efficacy with each having its own advantages and limitations. AREAS COVERED The purpose of this perspective is to delineate the limitations encountered in implementing cognitive behavioral therapy (CBT) and to review the pharmacological treatments designed to target the different phenotypes of insomnia. The discussions address how to choose the optimal medication or combination thereof based on patients' characteristics, available medications, and the presence of comorbid conditions. Selective nonbenzodiazepine sedative 'Z-drug' hypnotics, melatonin receptor agonist-ramelteon, and low-dose doxepin are the agents of choice for treatment of primary and comorbid insomnia. EXPERT OPINION A pharmacological intervention should be offered if cognitive behavioral therapy for insomnia is not available or has failed to achieve its goals. Increasing evidence of the significant adverse consequences of long-term benzodiazepines should limit the prescription of these agents to specific conditions. Testing novel dosing regimens with a combination of hypnotic classes augmented with CBT deserve further investigation.
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Affiliation(s)
- Amanda B Hassinger
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Nikolas Bletnisky
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Rizwan Dudekula
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA
| | - Ali A El-Solh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY, USA.,VA Western New York Healthcare System , Buffalo, NY, USA.,Department of Epidemiology and Environmental Health, Research and Development, School of Public Health, University at Buffalo , Buffalo, NY, USA
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18
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19
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Chancay MG, Guendsechadze SN, Blanco I. Types of pain and their psychosocial impact in women with rheumatoid arthritis. Womens Midlife Health 2019; 5:3. [PMID: 31417683 PMCID: PMC6688257 DOI: 10.1186/s40695-019-0047-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/01/2019] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.
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Affiliation(s)
- Maria Gabriela Chancay
- 1Department of Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Ave, Forchh 701N, Bronx, NY 10461 USA
| | | | - Irene Blanco
- 1Department of Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Ave, Forchh 701N, Bronx, NY 10461 USA
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20
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Moriarty F, Cahir C, Bennett K, Fahey T. Economic impact of potentially inappropriate prescribing and related adverse events in older people: a cost-utility analysis using Markov models. BMJ Open 2019; 9:e021832. [PMID: 30705233 PMCID: PMC6359741 DOI: 10.1136/bmjopen-2018-021832] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To determine the economic impact of three drugs commonly involved in potentially inappropriate prescribing (PIP) in adults aged ≥65 years, including their adverse effects (AEs): long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), benzodiazepines and proton pump inhibitors (PPIs) at maximal dose; to assess cost-effectiveness of potential interventions to reduce PIP of each drug. DESIGN Cost-utility analysis. We developed Markov models incorporating the AEs of each PIP, populated with published estimates of probabilities, health system costs (in 2014 euro) and utilities. PARTICIPANTS A hypothetical cohort of 65 year olds analysed over 35 1-year cycles with discounting at 5% per year. OUTCOME MEASURES Incremental cost, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios with 95% credible intervals (CIs, generated in probabilistic sensitivity analysis) between each PIP and an appropriate alternative strategy. Models were then used to evaluate the cost-effectiveness of potential interventions to reduce PIP for each of the three drug classes. RESULTS All three PIP drugs and their AEs are associated with greater cost and fewer QALYs compared with alternatives. The largest reduction in QALYs and incremental cost was for benzodiazepines compared with no sedative medication (€3470, 95% CI €2434 to €5001; -0.07 QALYs, 95% CI -0.089 to -0.047), followed by NSAIDs relative to paracetamol (€806, 95% CI €415 and €1346; -0.07 QALYs, 95% CI -0.131 to -0.026), and maximal dose PPIs compared with maintenance dose PPIs (€989, 95% CI -€69 and €2127; -0.01 QALYs, 95% CI -0.029 to 0.003). For interventions to reduce PIP, at a willingness-to-pay of €45 000 per QALY, targeting NSAIDs would be cost-effective up to the highest intervention cost per person of €1971. For benzodiazepine and PPI interventions, the equivalent cost was €1480 and €831, respectively. CONCLUSIONS Long-term benzodiazepine and NSAID prescribing are associated with significantly increased costs and reduced QALYs. Targeting inappropriate NSAID prescribing appears to be the most cost-effective PIP intervention.
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Affiliation(s)
- Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitriona Cahir
- 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
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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21
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Atkin T, Comai S, Gobbi G. Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery. Pharmacol Rev 2018; 70:197-245. [PMID: 29487083 DOI: 10.1124/pr.117.014381] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α2δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H1 antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.
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Affiliation(s)
- Tobias Atkin
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University Health Center, McGill University, Montreal, Quebec, Canada (T.A., S.C., G.G.); and Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.)
| | - Stefano Comai
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University Health Center, McGill University, Montreal, Quebec, Canada (T.A., S.C., G.G.); and Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.)
| | - Gabriella Gobbi
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University Health Center, McGill University, Montreal, Quebec, Canada (T.A., S.C., G.G.); and Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.)
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22
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Daiello LA, Tannenbaum C. Patient-Oriented Policies To Reduce The Harmful Effects Of Medication On Seniors' Brain Function. ACTA ACUST UNITED AC 2018; 28:124-128. [PMID: 30449999 DOI: 10.1093/ppar/pry031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Lori A Daiello
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI.,Alzheimer's Disease and Memory Disorders Center, Rhode Island Hospital, Providence, RI
| | - Cara Tannenbaum
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Canadian Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Canada
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Trends of cost-effectiveness studies in sleep medicine. Sleep Med 2018; 53:176-180. [PMID: 30282589 DOI: 10.1016/j.sleep.2018.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 12/12/2022]
Abstract
Economic analyses, and cost-effectiveness studies in particular, are increasingly used in medicine and population health to inform policy making and resource allocation. Health economic models have successfully captured sleep medicine outcomes. This study provides an overview of the growth of the use of cost-effectiveness analyses to quantify the outcomes of sleep related interventions. It also identifies highly prevalent sleep disorders, which despite having a high burden of disease, lack basic utility studies.
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Mager DR, Iannino-Renz R. Use of Sedative-Hypnotic Drugs Among Older Adults. J Community Health Nurs 2018; 34:63-68. [PMID: 28467209 DOI: 10.1080/07370016.2017.1304144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The purpose of this study was to reduce numbers of concurrently ordered sedative-hypnotic drugs for older adults in long-term (N = 220) and home-care (N = 357) settings. All active records were reviewed and numbers of sedative-hypnotics per patient were documented. Upon record review completion, educational sessions focused on dangers posed by use of multiple sedative-hypnotics were presented to nurses. One month posteducation, researchers reviewed the same records to evaluate changes. Matched pair t-tests suggested significant decreases in sedative-hypnotic use in long term, but not in the home care setting. Education in this area is critical within and across community settings.
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Affiliation(s)
- Diana R Mager
- a Egan School of Nursing , Fairfield University , Fairfield , Connecticut
| | - Rose Iannino-Renz
- a Egan School of Nursing , Fairfield University , Fairfield , Connecticut
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Marti J, Bachhuber M, Feingold J, Meads D, Richards M, Hennessy S. Financial incentives to discontinue long-term benzodiazepine use: a discrete choice experiment investigating patient preferences and willingness to participate. BMJ Open 2017; 7:e016229. [PMID: 28988167 PMCID: PMC5640034 DOI: 10.1136/bmjopen-2017-016229] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Investigate the acceptability of financial incentives for initiating a medically supervised benzodiazepine discontinuation programme among people with long-term benzodiazepine use and to identify programme features that influence willingness to participate. METHODS We conducted a discrete choice experiment in which we presented a variety of incentive-based programs to a sample of older adults with long-term benzodiazepine use identified using the outpatient electronic health record of a university-owned health system. We studied four programme variables: incentive amount for initiating the programme, incentive amount for successful benzodiazepine discontinuation, lottery versus certain payment and whether partial payment was given for dose reduction. Respondents reported their willingness to participate in the programmes and additional information was collected on demographics, history of use and anxiety symptoms. RESULTS The overall response rate was 28.4%. Among the 126 respondents, all four programme variables influenced stated preferences. Respondents strongly preferred guaranteed cash-based incentives as opposed to a lottery, and the dollar amount of both the starting and conditional incentives had a substantial impact on choice. Willingness to participate increased with the amount of conditional incentive. Programme participation also varied by gender, duration of use and income. CONCLUSIONS Participation in an incentive-based benzodiazepine discontinuation programme might be relatively low, but is modifiable by programme variables including incentive amounts. These results will be helpful to inform the design of future trials of benzodiazepine discontinuation programmes. Further research is needed to assess the financial viability and potential cost-effectiveness of such economic incentives.
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Affiliation(s)
- Joachim Marti
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Marcus Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael Richards
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
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Scullin MK. Do Older Adults Need Sleep? A Review of Neuroimaging, Sleep, and Aging Studies. CURRENT SLEEP MEDICINE REPORTS 2017; 3:204-214. [PMID: 29226069 PMCID: PMC5720383 DOI: 10.1007/s40675-017-0086-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Sleep habits, sleep physiology, and sleep disorders change with increasing age. However, there is a longstanding debate regarding whether older adults need sleep to maintain health and daily functioning (reduced-sleep-need view). An alternative possibility is that all older adults need sleep, but that many older adults have lost the ability to obtain restorative sleep (reduced-sleep-ability view). Prior research using behavioral and polysomnography outcomes has not definitively disentangled the reduced-sleep-need and reduced-sleep-ability views. Therefore, this review examines the neuroimaging literature to determine whether age-related changes in sleep cause-or are caused by-age-related changes in brain structure, function, and pathology. RECENT FINDINGS In middle-aged and older adults, poorer sleep quality, greater nighttime hypoxia, and shorter sleep duration related to cortical thinning in frontal regions implicated in slow wave generation, in frontoparietal networks implicated in cognitive control, and in hippocampal regions implicated in memory consolidation. Furthermore, poor sleep quality was associated with higher amyloid burden and decreased connectivity in the default mode network, a network that is disrupted in the pathway to Alzheimer's disease. SUMMARY All adults need sleep, but cortical thinning and amyloidal deposition with advancing age may weaken the brain's ability to produce restorative sleep. Therefore, sleep in older adults may not always support identical functions for physical, mental, and cognitive health as in young adults.
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Affiliation(s)
- Michael K Scullin
- Department of Psychology and Neuroscience, Baylor University, Waco, TX
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Abstract
Difficulty initiating and/or maintaining sleep is a common issue. Patients experiencing insomnia symptoms frequently self-treat their symptoms with sleep medications. However, there remains concern regarding the short- and long-term health impacts of sleep medications. This article discusses the evidence supporting integrative approaches to insomnia treatment, including cognitive-behavioral therapy and mind-body therapies (mindfulness meditation, yoga, tai chi), as well as emerging data for use of other less well supported approaches (dietary supplements, acupuncture).
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Affiliation(s)
- Eric S Zhou
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA.
| | - Paula Gardiner
- Boston Medical Center, Boston University School of Medicine, 1 Boston Medical Center Place, Boston, MA 02218, USA
| | - Suzanne M Bertisch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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Cook WA, Morrison ML, Eaton LH, Theodore BR, Doorenbos AZ. Quantity and Quality of Economic Evaluations in U.S. Nursing Research, 1997-2015: A Systematic Review. Nurs Res 2017; 66:28-39. [PMID: 27893648 PMCID: PMC5159252 DOI: 10.1097/nnr.0000000000000188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The United States has a complex healthcare system that is undergoing substantial reformations. There is a need for high-quality, economic evaluations of nursing practice. An updated review of completed economic evaluations relevant to the field of nursing within the U.S. healthcare system is timely and needed. OBJECTIVES The purpose of this study was to evaluate and describe the quantity and quality of economic evaluations in nursing-relevant research performed in the United States between 1997 and 2015. METHODS Four databases were searched. Titles, abstracts, and full-text content were reviewed to identify studies that analyzed both costs and outcomes, relevant to nursing, performed in the United States, and used the quality-adjusted life year to measure effectiveness. For included studies, data were extracted from full-text articles using criteria from U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. RESULTS Twenty-eight studies met the inclusion criteria. Most (n = 25, 89%) were published in the last decade of the analysis, from 2006 to 2015. Assessment of quality, based on selected items from the panel guidelines, found that the evaluations did not consistently use the recommended societal perspective, use multiple resource utilization categories, use constant dollars, discount future costs and outcomes, use a lifetime horizon, or include an indication of uncertainty in results. The only resource utilization category consistently included across studies was healthcare resources. DISCUSSION Only 28 nursing-related studies meeting the inclusion criteria were identified as meeting robust health economic evaluation methodological criteria, and most did not include all important guideline items. Despite increases in absolute numbers of published studies over the past decade, economic evaluation has been underutilized in U.S. nursing-relevant research in the past two decades.
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Affiliation(s)
- Wendy A Cook
- Wendy A. Cook, PhD, RN, CCNS, is U.S. Navy Nurse Corps Nurse Scientist, Naval Medical Center San Diego, California, and Affiliate Assistant Professor, School of Nursing, University of Washington, Seattle. Megan L. Morrison, PhD, ARNP, FNP-BC, ACHPN, is Palliative and Supportive Care Attending Nurse Practitioner, Northwest Hospital and Medical Center, Seattle, Washington. Linda H. Eaton, PhD, RN, AOCN, is Project Director, Pain and Symptom Management in Rural Communities, School of Nursing, University of Washington, Seattle, and Post-Doctoral Research Fellow, University of Utah College of Nursing, Salt Lake City. Brian R. Theodore, PhD, is Research Assistant Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle. Ardith Z. Doorenbos, PhD, RN, FAAN, is Professor, School of Nursing and School of Medicine, University of Washington, Seattle
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Reynolds SA, Ebben MR. The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment. Sleep Med Clin 2017; 12:39-46. [DOI: 10.1016/j.jsmc.2016.10.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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30
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An Ecological Approach to Reducing Potentially Inappropriate Medication Use: Canadian Deprescribing Network. Can J Aging 2017; 36:97-107. [PMID: 28091333 DOI: 10.1017/s0714980816000702] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Polypharmacy is growing in Canada, along with adverse drug events and drug-related costs. Part of the solution may be deprescribing, the planned and supervised process of dose reduction or stopping of medications that may be causing harm or are no longer providing benefit. Deprescribing can be a complex process, involving the intersection of patients, health care providers, and organizational and policy factors serving as enablers or barriers. This article describes the justification, theoretical foundation, and process for developing a Canadian Deprescribing Network (CaDeN), a network of individuals, organizations, and decision-makers committed to promoting the appropriate use of medications and non-pharmacological approaches to care, especially among older people in Canada. CaDeN will deploy multiple levels of action across multiple stakeholder groups simultaneously in an ecological approach to health system change. CaDeN proposes a unique model that might be applied both in national settings and for different transformational challenges in health care.
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31
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Alessi C, Martin JL, Fiorentino L, Fung CH, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Josephson K, Jouldjian S, Mitchell MN. Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:1830-8. [PMID: 27550552 DOI: 10.1111/jgs.14304] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians. DESIGN Randomized controlled trial. SETTING Department of Veterans Affairs healthcare system. PARTICIPANTS Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). INTERVENTION Nonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. MEASUREMENTS Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)). RESULTS Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. CONCLUSION Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.
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Affiliation(s)
- Cathy Alessi
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California. .,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Lavinia Fiorentino
- Department of Psychiatry, University of California at San Diego, San Diego, California
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Joseph M Dzierzewski
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Juan C Rodriguez Tapia
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.,Department of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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Garland SN, Zhou ES, Gonzalez BD, Rodriguez N. The Quest for Mindful Sleep: A Critical Synthesis of the Impact of Mindfulness-Based Interventions for Insomnia. CURRENT SLEEP MEDICINE REPORTS 2016; 2:142-151. [PMID: 28191449 DOI: 10.1007/s40675-016-0050-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Mindfulness-Based Interventions (MBIs) for insomnia and sleep disturbances are receiving increasing clinical and research attention. This paper provides a critical appraisal of this growing area investigating the application of MBIs for people with insomnia and sleep disturbance. First, we discuss the theoretical justification for how mindfulness meditation practice may affect sleep processes. Second, we provide a focused review of literature published between January 1, 2012 and April 1, 2016 examining the impact of MBIs on sleep, broken down by whether insomnia or sleep disturbance was a primary or secondary outcome. Recommendations for future research are discussed.
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Affiliation(s)
- Sheila N Garland
- Department of Psychology, Faculty of Science, Memorial University of Newfoundland, 232 Elizabeth Avenue, St. John's Newfoundland, Canada. A1B 3X9; Division of Oncology, Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Phillip Dr., St. John's, Newfoundland, Canada. A1B 3V6
| | - Eric S Zhou
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA. 02115; Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA. 02215
| | - Brian D Gonzalez
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08903
| | - Nicole Rodriguez
- Department of Psychology, Faculty of Science, Memorial University of Newfoundland, 232 Elizabeth Avenue, St. John's Newfoundland, Canada. A1B 3X9
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Morgan SG, Weymann D, Pratt B, Smolina K, Gladstone EJ, Raymond C, Mintzes B. Sex differences in the risk of receiving potentially inappropriate prescriptions among older adults. Age Ageing 2016; 45:535-42. [PMID: 27151390 PMCID: PMC4916346 DOI: 10.1093/ageing/afw074] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/23/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences. Design: a retrospective cohort study. Setting: community setting of British Columbia, Canada. Participants: residents of British Columbia aged 65 and older (n = 660,679). Measurements: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors. Results: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12–1.21). Much of this sex difference stemmed from women's increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs. Conclusion: there are significant sex differences in older adults' risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients.
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Affiliation(s)
- Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada V6T1Z3
| | - Deirdre Weymann
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada V6T1Z3
| | | | - Kate Smolina
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada V6T1Z3
| | - Emilie J Gladstone
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada V6T1Z3
| | - Colette Raymond
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada
| | - Barbara Mintzes
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
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Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res 2016; 5:918. [PMID: 27303633 PMCID: PMC4890308 DOI: 10.12688/f1000research.8729.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2017] [Indexed: 09/02/2023] Open
Abstract
This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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35
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Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000Res 2016; 5:918. [PMID: 27303633 PMCID: PMC4890308 DOI: 10.12688/f1000research.8729.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 12/14/2022] Open
Abstract
This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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36
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Abstract
This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.
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Affiliation(s)
- Daniel F. Kripke
- University of California, San Diego, La Jolla, CA, 92037-2226, USA
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37
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Morgan SG, Hunt J, Rioux J, Proulx J, Weymann D, Tannenbaum C. Frequency and cost of potentially inappropriate prescribing for older adults: a cross-sectional study. CMAJ Open 2016; 4:E346-51. [PMID: 27398383 PMCID: PMC4933607 DOI: 10.9778/cmajo.20150131] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many medications pose greater health risks when prescribed for older adults, compared with available pharmacologic and nonpharmacologic alternatives. We sought to quantify the frequency and cost of potentially inappropriate prescribing for older women and men in Canada. METHODS Using data for 2013 from the National Prescription Drug Utilization Information System database, which contains prescription claims from publicly financed drug plans in all provinces except for Quebec, we identified the frequency of prescribing and cost of potentially inappropriate medications dispensed to provincial drug plan enrollees aged 65 years or more. Potentially inappropriate prescriptions were defined with the use of the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. RESULTS For the 6 provinces with relatively complete data coverage (British Columbia, Alberta, Saskatchewan, Manitoba, Ontario and Prince Edward Island), 37% of older people filled 1 or more prescription meeting the Beers Criteria. A higher proportion of women (42%) than men (31%) filled potentially inappropriate prescriptions. The highest rates of prescribing of potentially inappropriate medications were among women aged 85 or more (47%). Benzodiazepines and other hypnotics were the leading contributors to the overall frequency of and sex differences in prescribing of potentially inappropriate drugs among older adults. We estimated that $75 per older Canadian, or $419 million in total, was spent on potentially inappropriate medications outside of hospital settings in 2013. INTERPRETATION Prescribing of potentially inappropriate medications for older adults is common and costly in Canada, especially for women. Multipronged and well-coordinated strategies to reduce the use and cost of potentially inappropriate drugs would likely generate significant health system savings while simultaneously generating major benefits to patient health.
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Affiliation(s)
- Steven G Morgan
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
| | - Jordan Hunt
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
| | - Jocelyn Rioux
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
| | - Jeffery Proulx
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
| | - Deirdre Weymann
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
| | - Cara Tannenbaum
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Canadian Institute for Health Information (Hunt, Rioux, Proulx), Ottawa, Ont.; BC Cancer Agency (Weymann), Canadian Centre for Applied Research in Cancer Control, Vancouver, BC; Departments of Medicine and Pharmacy (Tannenbaum), Université de Montréal, Montréal, Que
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38
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Wickwire EM, Shaya FT, Scharf SM. Health economics of insomnia treatments: The return on investment for a good night's sleep. Sleep Med Rev 2015; 30:72-82. [PMID: 26874067 DOI: 10.1016/j.smrv.2015.11.004] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 11/20/2015] [Accepted: 11/23/2015] [Indexed: 11/20/2022]
Abstract
Chronic insomnia is the most common sleep disorder among adults and is associated with a wide range of negative outcomes. This article reviews the economic consequences of the disorder and the cost effectiveness of insomnia treatments. First, the total costs of insomnia are reviewed; in aggregate these costs exceed $100 billion USD per year, with the majority being spent on indirect costs such as poorer workplace performance, increased health care utilization, and increased accident risk. Next, the deleterious impact of insomnia on quality of life and the impact of treatment on quality of life are briefly considered. Finally, ten published studies evaluating the cost effectiveness of both pharmacological and behavioral treatments for insomnia are reviewed in detail. A significant majority of studies reviewed found that the cost of treating primary and comorbid insomnia is less than the cost of not treating it. Treatments were generally found to be cost-effective using commonly employed standards, with treatment costs being recouped within 6-12 mo.
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Affiliation(s)
- Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, 100 N Greene St, 2nd Floor Baltimore, MD 21201, USA; Sleep Disorders Center, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 100 N Greene St, 2nd Floor Baltimore, MD 21201, USA
| | | | - Steven M Scharf
- Department of Medicine, Division of Pulmonary and Critical Care, University of Maryland School of Pharmacy, USA
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