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Chua S, Todd A, Reeve E, Smith SM, Fox J, Elsisi Z, Hughes S, Husband A, Langford A, Merriman N, Harris JR, Devine B, Gray SL. Deprescribing interventions in older adults: An overview of systematic reviews. PLoS One 2024; 19:e0305215. [PMID: 38885276 PMCID: PMC11182547 DOI: 10.1371/journal.pone.0305215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults. METHODS 11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). RESULTS We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment. CONCLUSION Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020178860.
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Affiliation(s)
- Shiyun Chua
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Adam Todd
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Emily Reeve
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Susan M. Smith
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Julia Fox
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Zizi Elsisi
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Stephen Hughes
- School of Pharmacy, University of Sydney, Sydney, Australia
| | - Andrew Husband
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Aili Langford
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Niamh Merriman
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Jeffrey R. Harris
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Beth Devine
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Shelly L. Gray
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, United States of America
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van Gestel LC, Adriaanse MA, Kanis SL, Mensink-Bout SM, Schoones JW, Numans ME, Kiefte-de Jong JC, van den Brink G. Determinants of and interventions for Proton Pump Inhibitor prescription behavior: A systematic scoping review. BMC PRIMARY CARE 2024; 25:208. [PMID: 38862886 PMCID: PMC11165893 DOI: 10.1186/s12875-024-02459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Proton Pump Inhibitors (PPI) are frequently prescribed. Long-term use is associated with side-effects and patients often lack a valid indication. Inappropriate PPI prescribing thus needs to be addressed. This review aims to scope 1) what determinants are studied as reasons for PPI prescribing, 2) what strategies are used for changing PPI (de)prescribing, and 3) whether important determinants are addressed in these interventions. METHODS We searched eight databases for papers on determinants of physician PPI prescribing. Studies were included if they were conducted in a Western country and focused on oral PPIs for an adult population. By following the Behaviour Change Wheel, we extracted information regarding PPI prescribing behavior, behavioral determinants and intervention strategies. FINDINGS We included 74 papers. Most focused on the determinants knowledge and beliefs about consequences. The latter was consistently related to PPI prescribing. Results for knowledge were mixed. Most interventions used education or enablement (e.g., algorithms, quality check improvements, involvement of pharmacists) as strategies. Enablement consistently improved PPI prescribing, while results for education were mixed. INTERPRETATION There is an overemphasis on reflective processes in studies on PPI prescribing. Future research should comprehensively identify behavioral determinants, focusing on reflective and impulsive processes, such that interventions can address the most important determinants.
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Affiliation(s)
- L C van Gestel
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands.
| | - M A Adriaanse
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S L Kanis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S M Mensink-Bout
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J W Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J C Kiefte-de Jong
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - G van den Brink
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Japelj N, Horvat N, Knez L, Kos M. Deprescribing: An umbrella review. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2024; 74:249-267. [PMID: 38815201 DOI: 10.2478/acph-2024-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 06/01/2024]
Abstract
This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.
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Affiliation(s)
- Nuša Japelj
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Nejc Horvat
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Lea Knez
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
- 2University Clinic Golnik 4204 Golnik, Slovenia
| | - Mitja Kos
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
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Kurlander JE, Laine L, Kim HM, Roberts CB, Saffar D, Myers A, Holleman R, Gao Y, Shank M, Nelson R, Forman J, Helfrich CD, Krein SL, Saini SD, Yang YX. Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. BMJ 2024; 385:e076484. [PMID: 38604668 PMCID: PMC11007585 DOI: 10.1136/bmj-2023-076484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. DESIGN Difference-in-difference study. SETTING US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. PARTICIPANTS All individuals receiving primary care from 2009 to 2019. INTERVENTION Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. MAIN OUTCOME MEASURES The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. RESULTS The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval -7.6% to -7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (-12.0% to -10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (-6.08% to -5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. CONCLUSIONS The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.
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Affiliation(s)
- Jacob E Kurlander
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Loren Laine
- Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Hyungjin Myra Kim
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Darcy Saffar
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Aimee Myers
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Robert Holleman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Yuqing Gao
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michelle Shank
- Department of Veterans Affairs, Pharmacy Services, Washington, DC, USA (retired)
| | - Richard Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jane Forman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Sarah L Krein
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sameer D Saini
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Yu-Xiao Yang
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rodrigues DA, Herdeiro MT, Mateos-Campos R, Figueiras A, Roque F. Magnitude and Determinants of Long-term Use of Proton Pump Inhibitors Among Portuguese Older Adults in Primary Health Care. Clin Ther 2024; 46:e54-e58. [PMID: 38061931 DOI: 10.1016/j.clinthera.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 02/27/2024]
Abstract
PURPOSE Proton Pump Inhibitors (PPIs) have been associated with several adverse effects of particular concern in older populations. Their use for a period longer than 8 weeks is not recommended for older adults. Strategies to discontinue PPIs have been offered; however, their use remains high. This study aims to characterize PPI use in Portuguese older people and to identify the factors associated with potentially inappropriate use. METHODS A cross-sectional study was conducted on 1200 randomly selected older adults (≥65 years of age), users of primary health care facilities in the Regional Health Administration (Administração Regional de Saúde of Centro [ARSC]) of Portugal between April 2021 and August 2022. Data concerning their characteristics and PPI use were provided by the Shared Services of the Health Ministry (Serviços Partilhados do Ministério da Saúde) and collected retrospectively. Associations between independent variables and PPI use were investigated by logistic regression analysis. FINDINGS Of the older adults, 37.92% were receiving PPIs and 78.68% of them were taking them for a longer period than recommended; 49.79% were taking PPIs without having any digestive system-related disease. Multivariate analysis showed that the prolonged use of PPIs was not associated with any specific pattern, although inappropriate PPI use is high among Portuguese older adults. IMPLICATIONS Long-term PPI use in older adults is widespread and does not fit any particular patient profile; therefore, cross-cutting educational interventions should be designed independently of the patient's pathologic condition or treatment.
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Affiliation(s)
- Daniela A Rodrigues
- Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), 6300-559, Guarda, Portugal; Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200-506, Covilhã, Portugal; PhD Student, University of Salamanca, 37007, Salamanca, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, 3810-193, Aveiro, Portugal
| | - Ramona Mateos-Campos
- Area of Preventive Medicine and Public Health, Department of Biomedical and Diagnostic Sciences, University of Salamanca, 37007, Salamanca, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702, Santiago de Compostela, Spain; Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001, Madrid, Spain
| | - Fátima Roque
- Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), 6300-559, Guarda, Portugal; Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200-506, Covilhã, Portugal.
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Heisig J, Bücker B, Schmidt A, Heye AL, Rieckert A, Löscher S, Hirsch O, Donner-Banzhoff N, Wilm S, Barzel A, Becker A, Viniol A. Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial. Sci Rep 2023; 13:21633. [PMID: 38062116 PMCID: PMC10703926 DOI: 10.1038/s41598-023-48839-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.
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Affiliation(s)
- Julia Heisig
- Department of Primary Care, University of Marburg, Marburg, Germany.
| | - Bettina Bücker
- Institute of General Practice (Ifam), Centre for Health and Society (Chs), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexandra Schmidt
- Chair of General Practice II and Patient-Centeredness in Primary Care, Institute of General Practice and Primary Care (IGPPC), Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Anne-Lisa Heye
- Chair of General Practice I and Interprofessional Care, Institute of General Practice and Primary Care (IGPPC), Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Anja Rieckert
- Chair of General Practice II and Patient-Centeredness in Primary Care, Institute of General Practice and Primary Care (IGPPC), Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Susanne Löscher
- Institute of General Practice (Ifam), Centre for Health and Society (Chs), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Oliver Hirsch
- Department of Psychology, FOM University of Applied Sciences, Siegen, Germany
| | | | - Stefan Wilm
- Institute of General Practice (Ifam), Centre for Health and Society (Chs), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Anne Barzel
- Department of General Practice and Primary Care, Ulm University Hospital, Ulm, Germany
| | - Annette Becker
- Department of Primary Care, University of Marburg, Marburg, Germany
| | - Annika Viniol
- Department of Primary Care, University of Marburg, Marburg, Germany
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Bai AD, Wilkinson A, Almufleh A, Rai M, Razak F, Verma AA, Srivastava S. Ceftriaxone and the Risk of Ventricular Arrhythmia, Cardiac Arrest, and Death Among Patients Receiving Lansoprazole. JAMA Netw Open 2023; 6:e2339893. [PMID: 37883084 PMCID: PMC10603497 DOI: 10.1001/jamanetworkopen.2023.39893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/11/2023] [Indexed: 10/27/2023] Open
Abstract
Importance The combination of ceftriaxone and lansoprazole has been shown to prolong the corrected QT interval on electrocardiogram. However, it is unknown whether this translates to clinically important patient outcomes. Objective To compare lansoprazole with another proton pump inhibitor (PPI) during ceftriaxone treatment in terms of risk for ventricular arrhythmia, cardiac arrest, and in-hospital mortality. Design, Setting, and Participants A retrospective cohort study including adult medical inpatients receiving ceftriaxone with lansoprazole or another PPI in 13 hospitals in Ontario, Canada, was conducted from January 1, 2015, to December 31, 2021. Exposure Lansoprazole during ceftriaxone treatment vs other PPIs during ceftriaxone treatment. Main Outcomes and Measures The primary outcome was a composite of ventricular arrhythmia or cardiac arrest that occurred after hospital admission. The secondary outcome was all-cause in-hospital mortality. Propensity-score weighting was used to adjust for covariates including hospital site, demographic characteristics, comorbidities, risk factors for ventricular arrhythmia, illness severity, admitting diagnoses, and concomitant medications. Results Of the 31 152 patients hospitalized on internal medicine wards who were treated with ceftriaxone while receiving a PPI, 16 135 patients (51.8%) were male, and the mean (SD) age was 71.7 (16.0) years. The study included 3747 patients in the lansoprazole group and 27 405 patients in the other PPI group. Ventricular arrhythmia or cardiac arrest occurred in 126 patients (3.4%) within the lansoprazole group and 319 patients (1.2%) within the other PPI group. In-hospital mortality occurred in 746 patients (19.9%) within the lansoprazole group and 2762 patients (10.1%) in the other PPI group. After weighting using propensity scores, the adjusted risk difference for the lansoprazole group minus other PPI group was 1.7% (95% CI, 1.1%-2.3%) for ventricular arrhythmia or cardiac arrest and 7.4% (95% CI, 6.1%-8.8%) for in-hospital mortality. Conclusions and Relevance The findings of this cohort study suggest that combination therapy with lansoprazole and ceftriaxone should be avoided. More studies are needed to determine whether these findings could be replicated in other populations and settings.
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Affiliation(s)
- Anthony D. Bai
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amelia Wilkinson
- Division of General Internal Medicine, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Aws Almufleh
- Division of Cardiology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Mandip Rai
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Amol A. Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Siddhartha Srivastava
- Division of General Internal Medicine, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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Analysis of deprescription strategies of proton pump inhibitors in primary care: a narrative review. Prim Health Care Res Dev 2023; 24:e14. [PMID: 36788753 PMCID: PMC9971848 DOI: 10.1017/s1463423623000026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Since the introduction of omeprazole in 1989, proton pump inhibitors (PPIs) have become the mainstream of treatment for acid-related pathologies, but nowadays, it is estimated that between 20% and 80% of people worldwide who are using PPIs are doing so without an approved indication. Overusing PPIs is known to involve a tremendous cost in financial terms, and many western countries have reported high spending on these medicines. OBJECTIVE We conducted a narrative review to evaluate PPI deprescription strategies carried out entirely or in collaboration with primary care and to identify factors that could influence the success of these strategies. METHOD This review was conducted in November 2022, following PRISMA guidelines. Four databases were searched: PubMed, Web of Science, Scopus and CINAHL Complete, using the MeSH terms 'proton pump inhibitors' AND 'deprescriptions'. RESULTS The search with the established criteria found eight studies. The different success rates obtained by the various studies analysed in this review may be due to the different methodologies used when establishing the protocols, sample selection and monitoring of the results. CONCLUSION We can conclude that the two factors related to the most successful strategies were a) the clarity and simplicity of the de-escalation protocols, in which patients were instructed on the measures to follow in the event of the reappearance of symptoms, and b) the training of the physicians responsible for deprescribing. Long-term conclusions cannot be drawn about the effectiveness of these protocols, given that the studies are limited in time. Other barriers to generalizing the results are the small sample size and the absence of control groups.
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Okamoto K, Harada T, Kosaka S, Kutsuna S. Deprescribing antacids after the diagnosis of Clostridioides difficile infection: A single-center observational study. J Infect Chemother 2023; 29:232-234. [PMID: 36503067 DOI: 10.1016/j.jiac.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/10/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
Overuse of antacids is associated with the development and recurrence of Clostridioides difficile infection (CDI). Discontinuation of unnecessary antacids for CDI management is advocated; however, the clinical pervasiveness on the discontinuation of antacids remains unclear. We conducted a single-center retrospective observational study to determine the rate of antacid discontinuation following CDI diagnosis. Among 51 patients (58 infections; median age 76.5 years, range 69-82; 53.5% women) treated with antimicrobials against C. difficile, 41 had been treated with antacids, and of these, 18 exhibited no indication for antacid administration. However, none had discontinued antacid use. While CDI provides an opportunity for antacid stewardship, it is not implemented in clinical practice. In addition to the efforts of individual clinicians, the dissemination of knowledge of the indications and side effects of antacids, establishment of a multidisciplinary support system, and creation and implementation of a clinical stewardship pathway are necessary to increase the deprescription of antacids in patients with CDI.
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Affiliation(s)
- Kana Okamoto
- Center of Postgraduate Clinical Training, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Taku Harada
- Department of Internal Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan; Division of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan.
| | - Shintaro Kosaka
- Department of Internal Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Satoshi Kutsuna
- Department of Infection Control, Osaka University Graduate School of Medicine, Faculty of Medicine, Osaka, Japan
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Ladjouzi N, Romdhani A, Zouloumis G, Schlatter J. Inappropriate proton pump inhibitor lansoprazole prescription in older adults hospitalized in long-term care unit. Ir J Med Sci 2022:10.1007/s11845-022-03207-3. [PMID: 36333472 PMCID: PMC10390349 DOI: 10.1007/s11845-022-03207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
Abstract
Purpose
We evaluated the use of the PPI treatment by physicians in older adults hospitalized in a long-term care unit.
Methods
We included 40 patients aged 65 years or older with a lansoprazole prescription hospitalized in long-term care unit from January 2018 to January 2022. Patient characteristics, gastroduodenal history, dose of lansoprazole, indication, days of prescription, and number of medications were collected from electronic patient records.
Results
The mean age of patients was 84.2 ± 9.3. Patients were taking between 5 and 24 (mean = 12.7, SD = 4.4) medications overall with 15 patients taking low dose of aspirin (75 mg daily) and 8 patients taking an antiplatelet. Most patients (82.5%) received once-daily lansoprazole treatment, 55% of whom took a dose of 15 mg. Five patients were treated with the maximum dose of lansoprazole 30 mg twice daily. Only seven patients had an appropriate indication. The minimum of treatment time was 3 days and the maximum was 1198 days; moreover, 24 patients (60%) were still in treatment.
Conclusion
Few PPI prescriptions had an indication in the patient’s electronic record. Prescriptions were ongoing with no date of discontinuation or re-evaluation.
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11
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Woodman RJ, Horwood C, Kunnel A, Hakendorf P, Mangoni AA. Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital. Front Pharmacol 2022; 13:888677. [PMID: 36313311 PMCID: PMC9614045 DOI: 10.3389/fphar.2022.888677] [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: 03/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions. Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021. Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds. Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.
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Affiliation(s)
- Richard J. Woodman
- Centre of Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aline Kunnel
- School of Mathematical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Paul Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- *Correspondence: Arduino A. Mangoni,
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12
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Tarabay RB, Osman MH, Aridi RS, Hlais SA, Beshara RY, Lakkis NA. The effect of a patient informative leaflet on chronic use of proton pump inhibitors in a primary care center: a randomized control trial. Hosp Pract (1995) 2022; 50:318-325. [PMID: 35993151 DOI: 10.1080/21548331.2022.2114743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Chronic non-medically indicated PPIs are highly prescribed worldwide. The long-term side effects of PPI must be wisely considered during an extended prescription duration. Our study purpose is to assess the impact of providing patients and physicians with educational guides on the rates of reducing or eliminating PPIs. DESIGN AND METHODS A controlled study targeting adult patients with chronic PPI use was conducted in a family medicine center in Beirut. Block randomization was employed. Patients (n = 140) were equally divided into an intervention group consisting of a patient-oriented informative and motivational leaflet and a control group having the same follow-up without having the leaflet. All participants filled a questionnaire. All participants received a short phone call in 2 and 6 months. An e-mail clarifying the objective of this study was sent to all physicians and supplemented with a PPI deprescribing algorithm. RESULTS At the 6-month follow-up, the rate of participants who talked to treating physicians about their PPI therapy was higher in the intervention group (p-value<0.0001), and the rate of participants who stepped down or off PPI was higher in the intervention group (p-value<0.0001). In participants who stepped down or off PPI, the reported breakthrough symptoms decreased over time (moderate: 24.2%, mild: 35.5%, and nil: 40.3% at 2-month follow-up; and moderate: 0%, mild: 55.4% and nil: 44.6% at 6-month follow-up; p-value<0.0001). CONCLUSION A low-intensity, low-cost, and easily replicable intervention encouraged a significant number of long-term users of PPIs to reduce or stop these medications without causing significant breakthrough symptoms.
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Affiliation(s)
- Rami B Tarabay
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Mona H Osman
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Riwa S Aridi
- Faculty of Pharmacy, Lebanese International University (LIU), Beirut, Lebanon
| | - Sani A Hlais
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon.,Department of Family Medicine, Saint Joseph University Beirut (USJ), Beirut, Lebanon
| | - Ranin Y Beshara
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Najla A Lakkis
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
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13
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Dumlu HI, Sancar M, Ozdemir A, Okuyan B. Impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients: a non-randomized controlled study. Int J Clin Pharm 2022; 44:914-921. [PMID: 35449351 DOI: 10.1007/s11096-022-01394-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults. AIM To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients. METHOD This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48 h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge. RESULTS The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription. CONCLUSION A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay. TRIAL REGISTRATION NCT05113667 (17 October 2021-registered retrospectively).
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Affiliation(s)
- Hatice Ikra Dumlu
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Mesut Sancar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Ali Ozdemir
- Department of Internal Medicine, Health Sciences University, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Betul Okuyan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey.
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14
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Toth JM, Jadhav S, Holmes HM, Sharma M. Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers. BMC Geriatr 2022; 22:306. [PMID: 35395728 PMCID: PMC8993456 DOI: 10.1186/s12877-022-02971-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background Proton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D. Methods This was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends. Results Overall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims. Conclusions The overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.
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Affiliation(s)
- Jennifer M Toth
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA.
| | - Saumil Jadhav
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Manvi Sharma
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
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15
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Mangoni AA, Jarmuzewska EA. Patient-Centricity: A Much-Needed Strategy to Enhance the Quality Use of Medicines in Older Patients. Curr Rev Clin Exp Pharmacol 2022; 17:1-2. [DOI: 10.2174/277243281701211223100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elzbieta A. Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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16
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Romano S, Figueira D, Teixeira I, Perelman J. Deprescribing Interventions among Community-Dwelling Older Adults: A Systematic Review of Economic Evaluations. PHARMACOECONOMICS 2022; 40:269-295. [PMID: 34913143 DOI: 10.1007/s40273-021-01120-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Deprescribing can reduce the use of inappropriate or unnecessary medication; however, the economic value of such interventions is uncertain. OBJECTIVE This study seeks to identify and synthetise the economic evidence of deprescribing interventions among community-dwelling older adults. METHODS Full economic evaluation studies of deprescribing interventions, conducted in the community or primary care settings, in community-dwelling adults aged ≥ 65 years were systematically reviewed. MEDLINE, EconLit, Scopus, Web of Science, CEA-TUFTS, CRD York and Google Scholar databases were searched from inception to February 2021. Two researchers independently screened all retrieved articles according to inclusion and exclusion criteria. The main outcome was the economic impact of the intervention from any perspective, converted into 2019 US Dollars. The World Health Organization threshold of 1 gross domestic product per capita was used to define cost effectiveness. Studies were appraised for methodological quality using the extended Consensus on Health Economics Criteria checklist. RESULTS Of 6154 articles identified by the search strategy, 14 papers assessing 13 different interventions were included. Most deprescribing interventions included some type of medication review with or without a supportive educational component (n = 11, 85%), and in general were delivered within a pharmacist-physician care collaboration. Settings included community pharmacies, primary care/outpatient clinics and patients' homes. All economic evaluations were conducted within a time horizon varying from 2 to 12 months with outcomes in most of the studies derived from a single clinical trial. Main health outcomes were reported in terms of quality-adjusted life-years, prevented number of falls and the medication appropriateness index. Cost effectiveness ranged from dominant to an incremental cost-effectiveness ratio of $112,932 per quality-adjusted life-year, a value above the country's World Health Organization threshold. Overall, 85% of the interventions were cost saving, dominated usual care or were cost effective considering 1 gross domestic product per capita. Nine studies scored > 80% (good) and two scored ≤ 50% (low) on critical quality appraisal. CONCLUSIONS There is a growing interest in economic evaluations of deprescribing interventions focused on community-dwelling older adults. Although results varied across setting, time horizon and intervention, most were cost effective according to the World Health Organization threshold. Deprescribing interventions are promising from an economic viewpoint, but more studies are needed.
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Affiliation(s)
- Sónia Romano
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal.
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Débora Figueira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Inês Teixeira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Julian Perelman
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Lisbon, Portugal
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17
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Nguyen-Soenen J, Rat C, Gaultier A, Schirr-Bonnans S, Tessier P, Fournier JP. Effectiveness of a multi-faceted intervention to deprescribe proton pump inhibitors in primary care: protocol for a population-based, pragmatic, cluster-randomized controlled trial. BMC Health Serv Res 2022; 22:219. [PMID: 35177042 PMCID: PMC8851828 DOI: 10.1186/s12913-022-07496-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/13/2022] [Indexed: 02/07/2023] Open
Abstract
Background Inappropriately using proton pump inhibitors (PPI) is associated with severe adverse drug reactions and may have major consequences on healthcare costs. Deprescribing (the process by which a healthcare professional supervises the withdrawal of an inappropriate medication, to manage polypharmacy and improve outcomes) should be considered when an inappropriate PPI prescription is identified. Deprescribing interventions directed solely to prescribers have limited efficacy and are rarely targeted to patients. The aim of this trial is to assess the efficacy of a multi-faceted intervention with patients and general practitioners (GPs) to deprescribe PPI. Methods We will conduct a pragmatic, cluster-randomized, population-based, controlled trial in two regions of Western France. GPs with practices with over 100 patients, and their adult patient to whom over 300 defined daily doses (DDD) of PPIs have been dispensed in the year before baseline will be included. A total of 1300 GPs and 33,000 patients will be cluster-randomized by GPs practices. Three arms will be compared: i) a multi-faceted intervention associating a) a patient education brochure about PPI deprescribing sent directly to patients (the brochure was designed using a mixed-methods study), and b) a personalized letter with the Bruyere’s PPI deprescribing algorithm sent to their respective GPs, or ii) a single intervention where only the GPs received the letter and algorithm, or iii) no intervention. The primary outcome will be PPI deprescribing, defined as the proportion of patients achieving at least a 50% decrease in the amount of PPI dispensed to them (DDD/year) at 12 months compared to baseline. Secondary outcomes will include incremental cost-utility ratio (using EQ-5D-5L scale and National Health Insurance’s database), acid rebound (using the Gastroesophageal Reflux Disease Impact Scale), and the patients’ attitudes towards deprescribing (using the French rPATD). Discussion Based on previous trials, we anticipate more than 10% “successful PPI deprescribing” in the multi-faceted intervention compared to the single intervention on GPs and the control arm. The study has been funded through a national grant and will be launched in autumn 2020, for early results by the end of 2022. Trial registration Clinicaltrials.gov NCT04255823; first registered on February 5, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07496-3.
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Affiliation(s)
- Jérôme Nguyen-Soenen
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France. .,SPHERE - UMR INSERM 1246, Université de Nantes, Université de Tours, Nantes, France.
| | - Cédric Rat
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France
| | - Aurélie Gaultier
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France.,Direction de la recherche, Plateforme de Méthodologie et Biostatistique, CHU Nantes, Nantes, France
| | - Solène Schirr-Bonnans
- CHU de Nantes, Service Évaluation Économique et Développement des Produits de Santé, Nantes Université, Nantes, France
| | - Philippe Tessier
- SPHERE - UMR INSERM 1246, Université de Nantes, Université de Tours, Nantes, France.,CHU de Nantes, Service Évaluation Économique et Développement des Produits de Santé, Nantes Université, Nantes, France
| | - Jean-Pascal Fournier
- Département de Médecine Générale, Faculté de Médecine, Université de Nantes, Nantes, France.,SPHERE - UMR INSERM 1246, Université de Nantes, Université de Tours, Nantes, France
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18
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Imparato RR, Toma TS. Proton pump inhibitor deprescription: A rapid review. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e19989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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Lazaridis LD, Rizos E, Bounou L, Theodorou-Kanakari A, Kalousios S, Mavroeidi EA, Roma M, Chatzidakis A, Vlachonicolou G, Miltiadou K, Gkolfakis P, Tziatzios G, Triantafyllou K. An educational intervention to optimize use of proton pump inhibitors in a Greek university hospital. Ann Gastroenterol 2021; 34:781-787. [PMID: 34815643 PMCID: PMC8596207 DOI: 10.20524/aog.2021.0654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background Misuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems. Methods We conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients' records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge. Results The rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients. Conclusions The rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.
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Affiliation(s)
- Lazaros-Dimitrios Lazaridis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Evripidis Rizos
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Lamprini Bounou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Anna Theodorou-Kanakari
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Sotirios Kalousios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Electra-Antonia Mavroeidi
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Maria Roma
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Alexandros Chatzidakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgia Vlachonicolou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Miltiadou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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20
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Wu H, Kouladjian O'Donnell L, Fujita K, Masnoon N, Hilmer SN. Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions. Int J Gen Med 2021; 14:3793-3807. [PMID: 34335046 PMCID: PMC8317936 DOI: 10.2147/ijgm.s253177] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023] Open
Abstract
Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.
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Affiliation(s)
- Harry Wu
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kenji Fujita
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Nashwa Masnoon
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia.,Department of Pharmacy, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
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21
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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22
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Olry de Labry Lima A, Marcos Marcos J, Marquina Marquez A, González Vera MDLÁ, Matas Hoces A, Bermúdez Tamayo C. Evidence for deprescription in primary care through an umbrella review. BMC FAMILY PRACTICE 2020; 21:100. [PMID: 32513110 PMCID: PMC7278115 DOI: 10.1186/s12875-020-01166-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a high prevalence of potentially inappropriate prescriptions in primary care. This is associated with more frequent adverse events, lower quality of life and more frequent visits to hospital accident & emergency departments. The aim of the present study is to summarise available evidence on the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals. METHODS We designed an umbrella review which includes nine systematic reviews. More than 50% of included studies were performed with adults in primary care. Two reviewers independently performed data extraction and analysis. RESULTS In considering studies of the effectiveness of interventions, it can be observed that the educational component of deprescription procedures is a key factor, whilst procedures tailored towards the patient's situation offer better results. With regards to studies involving healthcare professionals, the main explored areas were the balance between risks and benefits, and the need to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. With regards to patients, it is clear that they have worries and doubts. In order to overcome these issues, a good relationship with healthcare professionals and receipt of their support is required during the process. CONCLUSIONS Optimizing medication through targeted deprescribing is an important part of managing chronic conditions, avoiding adverse effects and improving outcomes. The majority of deprescription interventions in primary care are effective. Good communication between healthcare professionals is a key element for success in the deprescription process.
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Affiliation(s)
- Antonio Olry de Labry Lima
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain. .,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain. .,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain.
| | - Jorge Marcos Marcos
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Public Health Research Group, University of Alicante, Alicante, Spain
| | - Alfonso Marquina Marquez
- Faculty of Education and Social Work, University of Valladolid, Valladolid, Spain.,GIESA, Applied Sociocultural Studies (SEJ208), University of Granada, Granada, Spain
| | | | - Antonio Matas Hoces
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Centro Andaluz de Información del Medicamento (CADIME), Campus Universitario de Cartuja, Granada, Spain
| | - Clara Bermúdez Tamayo
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain.,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain
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23
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Mehta N, Martinez Guasch F, Kamen C, Shah S, Burry LD, Soong C, Mehta S. Proton Pump Inhibitors in the Elderly Hospitalized Patient: Evaluating Appropriate Use and Deprescribing. J Pharm Technol 2020; 36:54-60. [PMID: 34752519 DOI: 10.1177/8755122519894953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Proton pump inhibitors (PPIs) are often prescribed for elderly patients without appropriate indication, or for longer durations than recommended. Objective: To review appropriateness of PPI use prior to and in hospital, and deprescribing rates across different hospital units. Methods: Retrospective analysis of patients ≥65 years admitted to 5 acute care units: intensive care unit, acute care for elderly, orthopedics, surgery, and medicine. Patients who were "non-naive" (prehospital PPI use) or "naive" (new PPI initiated in hospital) users were included. For both groups, demographics, reason for admission, length of stay, comorbidities, name and number of home medications, PPI name, dose and indication, and PPI discharge instructions were collected. For naive patients, duration of in-hospital use and prescriber specialty was recorded. Results: Among non-naive patients (n = 377), for 37 patients (10%), the indication for a PPI was not appropriate, and for 92 patients (24%), the indication was unclear. Most patients had their home PPI continued while in hospital (87%) and at discharge (90%). Among naive (n = 93) patients, for 8 patients (9%), the indication for a PPI was not appropriate, and for 25 (27%) patients, the indication was unclear. PPI was prescribed to only 16 (18%) by the gastrointestinal consult service. Most patients had their new PPI continued at discharge (74%); only 7 (9%) were discharged with a plan to reassess PPI indication. Conclusion: PPIs are infrequently deprescribed during hospital admission, despite inappropriate or unclear indications for use. Thorough medication reconciliation, documentation of PPI indication and duration, and institutional focus on deprescribing are encouraged.
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Affiliation(s)
- Nishila Mehta
- Faculty of Medicine, University of Toronto, Toronto ON, Canada
| | | | - Corey Kamen
- Faculty of Medicine, University of Toronto, Toronto ON, Canada
| | - Sumesh Shah
- Sinai Health System, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa D Burry
- Sinai Health System, Toronto, ON, Canada.,Department of Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Sangeeta Mehta
- Sinai Health System, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
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24
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Reassessment of inappropriate prescriptions of proton pump inhibitors in elderly in-patients: It's time to take action. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 78:150-157. [DOI: 10.1016/j.pharma.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
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25
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Walker MJ, Crews NR, El-Halabi M, Fayad NF. Educational Intervention Improves Proton Pump Inhibitor Stewardship in Outpatient Gastroenterology Clinics. Gastroenterology Res 2019; 12:305-311. [PMID: 31803310 PMCID: PMC6879027 DOI: 10.14740/gr1238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Background Improper chronic proton pump inhibitor (PPI) use has risen significantly in the last few decades. In our gastroenterology trainees’ clinics, we aimed to optimize PPI usage. Methods We collected baseline data on patients’ PPI use for 8 weeks. Based on gastroenterology society guidelines, we determined conditions for appropriate PPI use. If the indication could not be determined, it was categorized as “unknown”. Generated from the three most frequent causes for inappropriate PPI use, interventions were developed to correct each issue. Following a brief educational session, trainees implemented these interventions over a subsequent 8-week interval. Results During our pre-intervention period, trainees evaluated 263 patients who were prescribed a PPI. In 49% of the cases, the use of PPI was deemed inappropriate. The most common reasons were: gastroesophageal reflux disease (GERD) which was never titrated to the lowest effective dose, twice daily dosing for Barrett’s esophagus (BE) chemoprevention and unknown indication. During our intervention period, trainees evaluated 145 patients prescribed a PPI for GERD with well-controlled symptoms in 101 cases. PPI had not been titrated to lowest effective dose in 37 cases prompting intervention which was successful in 23 cases. PPI indication was unknown in 17 cases prompting a message to the prescribing provider to review appropriateness. Two cases of BE chemoprevention with twice daily dosing were appropriately reduced to daily dosing. Ultimately, after intervention, PPI use was deemed appropriate after intervention in 172 (77%) cases. Conclusions Improper chronic PPI use was significant. Focusing intervention efforts on PPI use for GERD, BE and unknown indications substantially increased appropriateness of PPI use.
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Affiliation(s)
- Megan J Walker
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Nicholas R Crews
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Mustapha El-Halabi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Nabil F Fayad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
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26
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Suitability of patient education materials on proton-pump inhibitors deprescribing: a focused review. Eur J Clin Pharmacol 2019; 76:17-21. [PMID: 31690956 DOI: 10.1007/s00228-019-02779-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Engaging patients in the process of deprescribing is a necessity. Several patient education materials have been developed for this purpose. The aim of this study was to assess the suitability of the existing patient education materials for proton-pump inhibitors deprescribing. METHODS We conducted a targeted inventory of the available materials on scientific literature and known repositories. We evaluated their suitability with the Suitability Assessment of Materials (SAM) instrument. Materials were rated independently by two researchers and then discussed until consensus was reached. RESULTS Seven patient education materials were identified. Three materials (42.9%) were deemed "superior" and 4 (57.1%) were deemed "adequate". Ratings were generally good in the categories of content, learning stimulation, motivation, typography and layout. The major weaknesses included the use of inappropriate graphics and the too demanding required reading grade level. These may decrease patient attention and comprehension and therefore the effectiveness of education materials. CONCLUSIONS Suitability of the patient education materials on proton-pump inhibitors deprescribing is overall satisfactory. Greater attention on readability, graphics and inclusion of summaries will be needed for development of future materials.
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27
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Komagamine J, Yabuki T, Kobayashi M. Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study. BMJ Open 2019; 9:e032574. [PMID: 31699748 PMCID: PMC6858212 DOI: 10.1136/bmjopen-2019-032574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan. DESIGN A prospective observational study conducted by using electronic medical records. PARTICIPANTS All consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded. MAIN OUTCOME MEASURES The primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression. RESULTS Seven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74-88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0-3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66). CONCLUSION The prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed. TRIAL REGISTRATION NUMBER UMIN000027189.
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Affiliation(s)
- Junpei Komagamine
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Taku Yabuki
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Masaki Kobayashi
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
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28
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Abstract
There is increasing concern among patients and health care providers about the associations between PPI use and a multitude of potential adverse outcomes. Therefore, clinicians need to have a rational approach both to identifying PPI users who may not have an ongoing indication for their use and on how to encourage discontinuation of unnecessary PPI use. In this paper, we will provide a detailed review of the specific indications where the benefits of ongoing PPI use is of questionable value and will review the evidence on how to maximize the likelihood of being able to successfully discontinue PPI use while minimizing symptom recurrence.
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29
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Zwietering NA, Westra D, Winkens B, Cremers H, van der Kuy PHM, Hurkens KP. Medication in older patients reviewed multiple ways (MORE) study. Int J Clin Pharm 2019; 41:1262-1271. [PMID: 31302885 PMCID: PMC6800858 DOI: 10.1007/s11096-019-00879-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 07/04/2019] [Indexed: 11/11/2022]
Abstract
Background Polypharmacy in older patients can lead to potentially inappropriate prescribing. The risk of the latter calls for effective medication review to ensure proper medication usage and safety. Objective Provide insight on the similarities and differences of medication review done in multiple ways that may lead to future possibilities to optimize medication review. Setting This study was conducted in Zuyderland Medical Centre, the second largest teaching hospital in the Netherlands. Method This descriptive study compares the quantity and content of remarks identified by medication review performed by a geriatrician, outpatient pharmacist, and Clinical Decision Support System. The content of remarks is categorized in seven categories of possible pharmacotherapeutic problems: ‘indication without medication’, ‘medication without indication’, ‘contra-indication/interaction/side-effect’, ‘dosage problem’, ‘double medication’, ‘incorrect medication’ and ‘therapeutic drug monitoring’. Main outcome measure Number and content of remarks on medication review. Results The Clinical Decision Support System (1.8 ± 0.8 vs. 0.9 ± 0.9, p < 0.001) and outpatient pharmacist (1.8 ± 0.8 vs. 0.9 ± 0.9, p = 0.045) both noted remarks in significantly more categories than the geriatricians. The Clinical Decision Support System provided more remarks on ‘double medication’, ‘dosage problem’ and ‘contraindication/interaction/side effects’ than the geriatrician (p < 0.050), while the geriatrician did on ‘medication without indication’ (p < 0.001). The Clinical Decision Support System noted significantly more remarks on ‘contraindication/interaction/side effects’ and ‘therapeutic drug monitoring’ than the outpatient pharmacist, whereas the outpatient pharmacist reported more on ‘indication without medication’ and ‘medication without indication’ than the Clinical Decision Support System (p ≤ 0.007). Conclusion Medication review performed by a geriatrician, outpatient pharmacist, and Clinical Decision Support System provides different insights and should be combined to create a more comprehensive report on medication profiles.
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Affiliation(s)
- N A Zwietering
- Department of Internal Medicine, Geriatric Medicine, Maastricht University Medical Centre, Maastricht University, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - D Westra
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - B Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - H Cremers
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - P H M van der Kuy
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - K P Hurkens
- Department of Internal Medicine, Geriatric Medicine, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
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30
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Hendrix I, Page AT, Korhonen MJ, Bell JS, Tan ECK, Visvanathan R, Cooper T, Robson L, Sluggett JK. Patterns of High-Dose and Long-Term Proton Pump Inhibitor Use: A Cross-Sectional Study in Six South Australian Residential Aged Care Services. Drugs Real World Outcomes 2019; 6:105-113. [PMID: 31264165 PMCID: PMC6702506 DOI: 10.1007/s40801-019-0157-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Aim While proton pump inhibitors (PPIs) are generally considered safe and well tolerated, frail older people who take PPIs long term may be susceptible to adverse events. This study characterized PPI use and determined factors associated with high-dose use among older adults in residential aged care services (RACSs). Methods A cross-sectional study of 383 residents of six South Australian RACSs within the same organization was conducted. Clinical, diagnostic, and medication data were collected by study nurses. The proportions of residents who took a PPI for > 8 weeks and without documented indications were calculated. Factors associated with high-dose PPI use compared to standard/low doses were identified using age- and sex-adjusted logistic regression models. Results 196 (51%) residents received a PPI, with 45 (23%) prescribed a high dose. Overall, 173 (88%) PPI users had documented clinical indications or received medications that can increase bleeding risk. Three-quarters of PPI users with gastroesophageal reflux disease or dyspepsia had received a PPI for > 8 weeks. High-dose PPI use was associated with increasing medication regimen complexity [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01–1.04 per one-point increase in Medication Regimen Complexity Index score] and a greater number of medications prescribed for regular use (OR 1.11; 95% CI 1.01–1.21 per additional medication). Conclusions Half of all residents received a PPI, of whom the majority had documented clinical indications or received medications that may increase bleeding risk. There remains an opportunity to review the continuing need for treatment and consider “step-down” approaches for high-dose PPI users.
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Affiliation(s)
- Ivanka Hendrix
- NHMRC Centre for Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia.,Adelaide Geriatrics Training and Research with Aged Care (GTRAC), School of Medicine, University of Adelaide, Adelaide, SA, Australia.,School of Nursing, University of Adelaide, Adelaide, SA, Australia.,Department of Pharmacy, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - Amy T Page
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia.,Centre for Optimisation of Medicines, School of Allied Health, Crawley, WA, Australia
| | - Maarit J Korhonen
- NHMRC Centre for Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia.,Institute of Biomedicine, University of Turku, Turku, Finland
| | - J Simon Bell
- NHMRC Centre for Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia.,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia.,School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia
| | - Edwin C K Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
| | - Renuka Visvanathan
- NHMRC Centre for Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Tina Cooper
- Resthaven Incorporated, Adelaide, SA, Australia
| | | | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia. .,NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia.
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31
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Mangoni AA, Bryant K, Jarmuzewska EA. Medication Management Issues in Old Age: A Call for Submissions to Current Clinical Pharmacology. ACTA ACUST UNITED AC 2019; 14:2-4. [PMID: 30968764 DOI: 10.2174/157488471401190301120237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia
| | - Kimberley Bryant
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia.,Department of Orthopaedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders, Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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32
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Prescriber Implementation of STOPP/START Recommendations for Hospitalised Older Adults: A Comparison of a Pharmacist Approach and a Physician Approach. Drugs Aging 2019; 36:279-288. [DOI: 10.1007/s40266-018-0627-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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33
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MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist's perspective. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2018; 7:41-52. [PMID: 29892570 PMCID: PMC5993040 DOI: 10.2147/iprp.s142932] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common gastrointestinal diagnosis, a leading reason for endoscopy and cause of potentially serious complications, resulting in significant individual and system-wide health burden. Approximately one quarter of people living in western countries have experienced GERD, and the prevalence appears to be on the rise. Risk factors for GERD include hiatus hernia, obesity, high-fat diet, tobacco smoking, alcohol consumption, pregnancy, genetics, and some medications. The cardinal symptoms of GERD are troublesome heartburn and regurgitation. GERD is identified by taking a patient-centered history and if necessary can be classified by endoscopic investigation. The role of the pharmacist in the management of GERD is to confirm the diagnosis by history taking, confirm there are no alarming signs or symptoms that require referral to a doctor, and recommendation of short-term therapy to control symptoms. Effective pharmacological treatments for GERD include antacids, alginate, histamine H2 receptor antagonists, and proton pump inhibitors. This narrative review includes a comparison of the efficacy and safety of these treatments and pertinent information to help pharmacists advise patients with GERD on their appropriate use.
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Affiliation(s)
- Brett MacFarlane
- Australian College of Pharmacy, Canberra, ACT, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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34
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Del Giorno R, Ceschi A, Pironi M, Zasa A, Greco A, Gabutti L. Multifaceted intervention to curb in-hospital over-prescription of proton pump inhibitors: A longitudinal multicenter quasi-experimental before-and-after study. Eur J Intern Med 2018; 50:52-59. [PMID: 29274884 DOI: 10.1016/j.ejim.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/03/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are indicated for a restricted number of clinical conditions, and their misuse can lead to several adverse effects. Despite that, the proportion of overuse is alarmingly high. OBJECTIVE To test the efficacy of a multifaceted strategy in order to achieve a significant reduction of new PPI prescriptions at discharge in hospitalized patients. DESIGN Multicenter longitudinal quasi-experimental before-and-after study conducted from July 1st, 2014 to June 30th, 2017. PARTICIPANTS 44,973 admissions in a network of 5 public teaching hospitals of the Italian-speaking region of Switzerland. INTERVENTION Multifaceted strategy consisting in a continuous transparent monitoring-benchmarking and in capillary educational interventions applied in the internal medicine departments. To confirm the causality of the results we monitored the trend of new PPI prescriptions in the, not exposed to the intervention, surgery departments of the same hospital network. MAIN MEASURES New PPI prescriptions at hospital discharge. KEY RESULTS Over the 36month study period 44,973 patient files were analyzed. At admission, comparing internal medicine vs. surgery departments, 44.9% vs. 23.3% of patients were already being treated with a PPI. The annual rate of new PPI prescriptions, for internal medicine showed a decreasing trend: 19, 19, 18, 16% in years 2014, 2015, 2016, 2017, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001), while an increasing rate was found in the surgery departments in the same years: 30, 29, 36, 36%, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001). The case mix was significantly associated with the probability of new PPI prescriptions in both departments (OR1.35, 95% CI 1.26-1.44 for internal medicine and 1.24, 95% CI 1.19-1.30 for surgery). CONCLUSIONS The introduction of a multifaceted intervention significantly reduced the time trend of PPI prescriptions at hospital discharge in internal medicine departments. Further studies are needed to confirm whether the strategy proposed could contribute to optimize the in-hospital drug prescription behavior in other healthcare settings as well.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland.
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
| | - Michela Pironi
- Central Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
| | - Anna Zasa
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland
| | - Angela Greco
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland.
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland; Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland.
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Naunton M, Peterson GM, Deeks LS, Young H, Kosari S. We have had a gutful: The need for deprescribing proton pump inhibitors. J Clin Pharm Ther 2017; 43:65-72. [PMID: 28895169 DOI: 10.1111/jcpt.12613] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 08/03/2017] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. METHODS Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. RESULTS AND DISCUSSION Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications. WHAT IS NEW AND CONCLUSION Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.
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Affiliation(s)
- M Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - G M Peterson
- University of Tasmania, Faculty of Health, University of Tasmania, Hobart, Tas., Australia
| | - L S Deeks
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - H Young
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - S Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
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