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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024:1-18. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [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: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Kassis A, Moles R, Carter S. Stakeholders' perspectives and experiences of the pharmacist's role in deprescribing in ambulatory care: A qualitative meta-synthesis. Res Social Adm Pharm 2024; 20:697-712. [PMID: 38685144 DOI: 10.1016/j.sapharm.2024.04.014] [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: 10/30/2023] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Deprescribing is an effective strategy to manage polypharmacy and improve patient outcomes. The notion of a potential role for pharmacists in a multidisciplinary team approach to deprescribing has been identified in quantitative and qualitative literature. However, stakeholders' perceptions of this role, and factors that may impede or facilitate the pharmacist's involvement have not been elucidated. The application in ambulatory care also requires clarification. Understanding stakeholders' views is essential to optimise involvement of the pharmacist in deprescribing and improve practice. OBJECTIVES First, to synthesize the perspectives and experiences of stakeholders (primary care providers, pharmacists, patients, and carers) regarding the role and involvement of the pharmacist in deprescribing in ambulatory care settings. Second, to identify barriers and strategies to enhancing pharmacist involvement in deprescribing. METHODS A systematic search was conducted across CINAHL, Embase, Medline, and Scopus from database inception to April 2023 for qualitative studies in English exploring the pharmacist's role in deprescribing. Data were extracted for iterative and inductive development of themes. A meta-synthesis facilitated the identification of overarching themes. Qualitative secondary analysis enabled identification of barriers and facilitators to the pharmacist's involvement in deprescribing. RESULTS From 285 articles identified, 9 studies were included which explored the views of general practitioners, specialist physicians, pharmacists, nurse practitioners, patients, carers, and general practice and clinic staff as stakeholders in deprescribing in ambulatory care. The meta-synthesis identified 4 over-arching themes: (1) therapeutic impetus and the status quo mentality, (2) role and responsibility, (3) multidisciplinary care, and (4) conflicting interests in pharmacy practice. Strategies to enhance pharmacists' involvement in deprescribing emerged from the data, and the pharmacist's role was strongly encouraged by stakeholders despite logistical and perceptual barriers identified. CONCLUSIONS Incorporation of the strategies to enhance the pharmacist's involvement in deprescribing identified in this review is encouraged to optimise patient-centred care and improve practice.
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Affiliation(s)
- Amanda Kassis
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.
| | - Rebekah Moles
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Stephen Carter
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
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Andriessen C, Blom MT, van Hoek BACE, de Boer AW, Denig P, de Wit GA, Swart K, de Rooij-Peek A, van Marum RJ, Hugtenburg JG, Slottje P, van Raalte D, van Bloemendaal L, Herings R, Nijpels G, Vos RC, Elders PJM. A deprescribing programme aimed to optimise blood glucose-lowering medication in older people with type 2 diabetes mellitus, the OMED2-study: the study protocol for a randomised controlled trial. Trials 2024; 25:505. [PMID: 39049109 PMCID: PMC11271055 DOI: 10.1186/s13063-024-08249-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/14/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Older patients with type 2 diabetes mellitus (T2D) have an increased risk of hypoglycaemic episodes when using sulphonylureas or insulin. In the Netherlands, guidelines exist for reducing glucose-lowering medication in older patients. However, evidence is lacking that a medication reduction in older patients can be safely pursued. Here, we will examine if promoting the deprescribing of insulin/sulphonylureas with a deprescribing programme (DPP) in general practice affects T2D-complications in older overtreated patients. METHODS We will perform a 1:1 cluster randomised controlled trial in 86 general practices in the Netherlands. The DPP will consist of education sessions with general practitioners and practice nurses about reducing glucose-lowering medication in older patients (≥ 70 years). Topics of the sessions include the necessity of deprescribing, tools to initiate deprescribing and strategies to discuss deprescribing with patients (shared decision making). The DPP further includes a support programme with practice visits. The study will employ a selection tool to identify possibly overtreated older patients from the electronic medical records of the general practitioner. Eligibility for enrolment in the study will be based on HbA1c targets indicated by the Dutch guidelines, which depend on age, diabetes duration, presence of frailty, and life expectancy. The control group will provide usual care. We aim to include 406 patients. The follow-up period will be 2 years. For the primary outcome, the effect of the DPP on T2D-complications will be assessed by counting the cumulative incidence of events related to under- and overtreatment in T2D as registered in the electronic medical records. We shall perform an intention-to-treat analysis and an analysis including only patients for whom deprescribing was initiated. The implementation of the DPP in general practice will be evaluated quantitatively and qualitatively using the Extended Normalisation Process Theory (ENPT) and the Reach, Efficacy - Adoption, Implementation and Maintenance (RE-AIM) model. Other secondary outcomes include quality of life, cognitive functioning, events related to overtreatment or undertreatment, biomarkers of health, amount of blood glucose-lowering medication prescriptions, and cost-effectiveness. DISCUSSION This study will provide insight into the safety and feasibility of a programme aimed at deprescribing sulphonylureas/insulin in older people with T2D who are treated in general practice. TRIAL REGISTRATION ISRCTN Registry, ISRCTN50008265 , registered 09 March, 2023.
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Affiliation(s)
- Charlotte Andriessen
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Marieke T Blom
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Beryl A C E van Hoek
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Anna W de Boer
- Department of Public Health and Primary Care / Health Campus The Hague, LUMC, Leiden, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - G Ardine de Wit
- Department of Health Sciences, Faculty of Beta Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Centre for Public Health, Healthcare and Society, National Institute of Public Health and the Environment, Bilthoven, the Netherlands
| | - Karin Swart
- PHARMO Institute for Drug Outcomes Studies, Utrecht, The Netherlands
| | | | - Rob J van Marum
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
- Department of Clinical Pharmacology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jacqueline G Hugtenburg
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Pauline Slottje
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Daniël van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Liselotte van Bloemendaal
- Department of Internal Medicine - Geriatrics, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Ron Herings
- PHARMO Institute for Drug Outcomes Studies, Utrecht, The Netherlands
| | - Giel Nijpels
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Rimke C Vos
- Department of Public Health and Primary Care / Health Campus The Hague, LUMC, Leiden, The Netherlands
| | - Petra J M Elders
- Department of General Practice, Amsterdam UMC, Location Vrije Universiteit, Meibergdreef 15, Amsterdam, 1105AZ, the Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
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Sprake E, Kung J, Graham M, Tsuyuki R, Gibson W. Deprescribing for older adults during acute care admission: a scoping review protocol. JBI Evid Synth 2024:02174543-990000000-00330. [PMID: 39005222 DOI: 10.11124/jbies-23-00406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
OBJECTIVE The objective of this scoping review is to understand the current body of knowledge regarding deprescribing in adults aged 60 and over in acute care settings, including the deprescribing activities that are being undertaken, and the feasibility, challenges, and outcomes of the practice. INTRODUCTION Polypharmacy is prevalent amongst older adults, despite risks to patients. Much of the existing research on deprescribing has occurred in the outpatient context, with recent research emerging on the unique opportunity that acute care may provide. INCLUSION CRITERIA This review will include deprescribing in adults aged 60 and older in acute care. It will consider deprescribing occurring during inpatient admission and at the time of discharge from hospital. METHODS The JBI method for scoping reviews will guide this review. A search of MEDLINE (Ovid), Scopus, Web of Science, CINAHL (EBSCOhost), Embase (Ovid), and the Cochrane Database will be undertaken from inception to present with no language restrictions. Qualitative, quantitative, and mixed method studies, clinical practice guidelines, and opinion papers will be considered for inclusion. Systematic reviews and scoping reviews will be excluded. Google Scholar and a general Google search will be conducted for gray literature. Two reviewers will assess articles for inclusion and any disagreements will be discussed and resolved by discussion or a third reviewer, if required. Findings will be presented in the scoping review using a narrative approach with supporting quantitative data in a tabular format according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR). REVIEW REGISTRATION Open Science Framework https://osf.io/pb7aw/.
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Affiliation(s)
- Erika Sprake
- Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Janice Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Michelle Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ross Tsuyuki
- Department of Medicine, EPICORE Center, University of Alberta, Edmonton, AB, Canada
| | - William Gibson
- Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Dijk MT, A M Pouw C, Hertogh CMPM, van Marum RJ, Hugtenburg JG, Smalbrugge M. Medication Appropriateness for Older Nursing Home Patients With a Limited Life Expectancy: From STOPP/START Version 2 to the ReNeWAL Criteria. J Am Med Dir Assoc 2024; 25:105143. [PMID: 38996809 DOI: 10.1016/j.jamda.2024.105143] [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: 02/22/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVES To adapt the 2015 Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria to older nursing home patients with a limited life expectancy of 1.5 to 2 years. DESIGN A modified Delphi consensus study. SETTING AND PARTICIPANTS The study was established in The Netherlands and conducted online. The international panel consisted of 23 experts with experience in medicine for older people. METHODS The expert panel was presented with the 2015 STOPP/START criteria using an online survey program (Survey Monkey). The panelists were asked for their opinion on the appropriateness of the STOPP and START criteria, and adaptations to these criteria for older nursing home patients with a limited life expectancy on 4-point Likert scales. Consensus was defined as ≥70% of the panelists answering (very) inappropriate or (very) appropriate, and (completely) disagree or (completely) agree. RESULTS Twenty-one panelists completed all 3 Delphi rounds. The final list of "Represcribing for Nursing home residents With A Limited life expectancy (ReNeWAL)" criteria comprises 132 criteria: 98 criteria to stop (70 original STOPP criteria and 28 adapted) and 34 criteria to start (16 original START criteria and 18 adapted) for older nursing home patients with a limited life expectancy. Considerations that panelists mentioned for adapting criteria were mainly prevention and treatment of discomfort. CONCLUSION AND IMPLICATIONS It is clear that represcribing for older nursing home patients is highly complex and requires the consideration of various elements. The ReNeWAL criteria may be useful in enhancing represcribing for older nursing home patients with a limited life expectancy.
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Affiliation(s)
- Margaretha T Dijk
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands.
| | - Catharina A M Pouw
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
| | - Rob J van Marum
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands; Geriatric Department and Center for Clinical Pharmacology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Jacqueline G Hugtenburg
- Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands; Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
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Stuijt PJC, Heringa M, van Dijk L, Faber A, Burgers JS, Feenstra TL, Taxis K, Denig P. Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation. BMC PRIMARY CARE 2024; 25:210. [PMID: 38862899 PMCID: PMC11165805 DOI: 10.1186/s12875-024-02465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (identifier: NCT05507177).
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Affiliation(s)
- Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Adrianne Faber
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Jako S Burgers
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Dutch National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands.
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Hickman E, Almaqhawi A, Gillies C, Khunti K, Seidu S. Beliefs, practices, perceptions and motivations of healthcare professionals on medication deprescribing during end-of-life care: A systematic review. Prim Care Diabetes 2024; 18:249-256. [PMID: 38443294 DOI: 10.1016/j.pcd.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
AIM Conduct a systematic review to investigate current beliefs, practices, perceptions, and motivations towards deprescribing practices from the healthcare professional perspective in older adults residing in long term care facilities with cardiometabolic conditions, using a narrative approach. METHODS Studies were identified using a literature search of MEDLINE, CINAHL and Web of Science from inception to June 2023 Two reviewers (EH and AA) independently extracted data from each selected study using a standardised self-developed data extraction proforma. Studies reviewed included cross-sectional and observational studies. Data was extracted on baseline characteristics, motivations and beliefs and was discussed using a narrative approach. RESULTS Eight studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction, or switching to an alternative medication, for at least one preventive medication. Most healthcare professionals were willing to initiate deprescribing strategies and stated the importance of such interventions, however many felt inexperienced and lacked the required knowledge to feel comfortable doing so. CONCLUSION Deprescribing is a key strategy when managing older people with cardiometabolic and multiple long term conditions (MLTC). Overall, HCPs including specialists, were happy to explore deprescribing strategies if provided with the relevant training and development to do so. Barriers that still exist include communication and consultation skills, a lack of evidence-based guidance and trust based policies, and a lack of MDT communications and involvement. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022335106.
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Affiliation(s)
- Elizabeth Hickman
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK.
| | - Abdullah Almaqhawi
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Clare Gillies
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Samuel Seidu
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
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Saka SA, Osineye TR. Considerations, barriers and enablers of deprescribing among healthcare professionals in Ogun State, Southwest, Nigeria: a cross-sectional survey. BMC Health Serv Res 2024; 24:661. [PMID: 38789975 PMCID: PMC11127322 DOI: 10.1186/s12913-024-11101-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Deprescribing is a clinical intervention aimed at managing polypharmacy and improving older adults' health outcomes. However, evidence suggests that healthcare professionals (HCPs) may face challenges in implementing the intervention. This study aimed to explore the considerations, barriers and enablers of deprescribing among HCPs in Southwest Nigeria. METHODS A quantitative cross-sectional survey was carried out among consecutively sampled HCPs including physicians, pharmacists and nurses in two public tertiary healthcare hospitals in Ogun State, Southwest, Nigeria. A structured 43-item self-administered questionnaire was used to explore the participants' sociodemographics, HCPs' experience, considerations, barriers and enablers of deprescribing in older adults. The data were summarised using descriptive statistics including frequency and percentage. The Kruskal-Wallis test was used to determine differences in perceptions among the groups on a Likert scale. A p-value < 0.05 was considered significant. RESULTS Overall, 453 copies of the questionnaire were analysed. Of the participants 204 (45.0%) were within the age group of 20-30 years; 173 (38.2%) claimed that older adults occasionally requested deprescribing of their medications. The majority (417; 92.1%) considered patients' quality of life to be very important in deprescribing; 423 (93.4%) opined that having a care goal known to members of the HCP team is an enabler for deprescribing while 308 (68.0%) disagreed or strongly disagreed that lack of incentives and remuneration for HCPs that de-prescribe is a barrier to deprescribing. There is a significant difference among the participants across professional groups on the assertion that pressure from pharmaceutical companies is a barrier to deprescribing in older adults (p = 0.037). CONCLUSIONS The participants in this study had various considerations for deprescribing medication in older adults including patients' quality of life. Having a care goal known to every HCP involved in managing a patient is an enabler for deprescribing while the lack of incentives and remuneration for HCPs that de-prescribe may not necessarily be a barrier to deprescribing. There is a need for regulations and policies to support the identified enablers among HCPs and reduce the barriers to effective deprescribing process.
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Affiliation(s)
- Sule Ajibola Saka
- Department of Clinical Pharmacy & Bio-Pharmacy, Olabisi Onabanjo University, Sagamu Campus, Nigeria.
| | - Tolulope Ruth Osineye
- Department of Clinical Pharmacy & Bio-Pharmacy, Olabisi Onabanjo University, Sagamu Campus, Nigeria
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Hung A, Kim YH, Pavon JM. Deprescribing in older adults with polypharmacy. BMJ 2024; 385:e074892. [PMID: 38719530 DOI: 10.1136/bmj-2023-074892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.
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Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Co-first authors
| | - Yoon Hie Kim
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Co-first authors
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center (GRECC) Durham VA Health Care System, Durham, NC, USA
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Schleiden LJ, Klima G, Rodriguez KL, Ersek M, Robinson JE, Hickson RP, Smith D, Cashy J, Sileanu FE, Thorpe CT. Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life. Drugs Aging 2024; 41:367-377. [PMID: 38575748 PMCID: PMC11021174 DOI: 10.1007/s40266-024-01110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Gloria Klima
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jacob E Robinson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - John Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Visser AGR, de-Bruijn JBGP, Spaetgens B, Winkens B, Janknegt R, Schols JMGA. Unlocking Deprescribing Potential in Nursing Homes: Insights from a Focus Group Study with Healthcare Professionals. Drugs Aging 2024; 41:261-270. [PMID: 38285238 PMCID: PMC10925566 DOI: 10.1007/s40266-023-01092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND The nursing home population is characterized by multimorbidity and disabilities, which often result in extensive prescription of medication and subsequent polypharmacy. Deprescribing, a planned and supervised process of dose reduction or total cessation of medication, is a solution to combat this. OBJECTIVE This study aimed to identify barriers and enablers of deprescribing as experienced by nursing home physicians (NHPs) and collaborating pharmacists in the specific nursing home setting. METHODS This qualitative study utilized a semi-structured interview format with two focus groups consisting of a mix of NHPs and pharmacists. Directed content analysis was performed based on the Theoretical Domains Framework, a validated framework for understanding determinants of behavior change among health care professionals. RESULTS Sixteen health care professionals participated in two focus groups, including 13 NHPs and three pharmacists. The participating NHPs and pharmacists believed that deprescribing is a valuable process with enablers, such as multidisciplinary collaboration, good communication with patients and family, and involvement of the nursing staff. NHPs and pharmacists view deprescribing as a core task and feel assured in their ability to carry it out successfully. However, they also noted barriers: deprescribing is time-consuming; communication with residents, their relatives or medical specialists is difficult; and electronic patient systems often do not adequately support it. CONCLUSIONS This study provides insight into the various barriers and enablers faced by NHPs and pharmacists when deprescribing in nursing homes. Specific for this population, deprescribing barriers focus on communication (with residents and their relatives, and also with medical specialists) and resources, while knowledge and expertise are mentioned as enablers.
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Affiliation(s)
- Anne G R Visser
- Zuyderland Nursing Homes, Sittard, The Netherlands.
- Departments of Health Services Research and Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - Jenny B G Poddighe de-Bruijn
- Departments of Health Services Research and Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Rob Janknegt
- Zuyderland Nursing Homes, Sittard, The Netherlands
| | - Jos M G A Schols
- Departments of Health Services Research and Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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13
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Mellot M, Jawal L, Morel T, Fournier JP, Tubach F, Cadwallader JS, Christiaens A, Zerah L. Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review. J Am Med Dir Assoc 2024; 25:439-447.e18. [PMID: 38237904 DOI: 10.1016/j.jamda.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVES Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. DESIGN Systematic review of qualitative and mixed-methods studies. SETTING AND PARTICIPANTS Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings. METHODS Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW). RESULTS We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints. CONCLUSIONS AND IMPLICATIONS The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.
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Affiliation(s)
- Marion Mellot
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France
| | - Lina Jawal
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France
| | - Thomas Morel
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France
| | - Jean-Pascal Fournier
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France; Université Tours-Nantes, INSERM, UMR U1246 SPHERE "Methods in Patient-Centered Outcomes and Health Research", Tours, France
| | - Florence Tubach
- Département de Santé Publique, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Jean-Sébastien Cadwallader
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Département de Médecine Générale, Sorbonne Université, Paris, France
| | - Antoine Christiaens
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Fonds de la Recherche Scientifique (FNRS), Brussels, Belgium; Clinical Pharmacy Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Lorène Zerah
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France.
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14
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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15
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Chung J, Tjia J, Zhang N, O'Connor BT. Anticholinergic Burden and Xerostomia in Critical Care Settings. Dimens Crit Care Nurs 2023; 42:310-318. [PMID: 37756502 DOI: 10.1097/dcc.0000000000000606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects. METHODS A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale. RESULTS Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia. CONCLUSIONS Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.
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Weir KR, Shang J, Choi J, Rana R, Vordenberg SE. Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation. JAMA Netw Open 2023; 6:e2337281. [PMID: 37819657 PMCID: PMC10568363 DOI: 10.1001/jamanetworkopen.2023.37281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Little is known about why older adults decline deprescribing recommendations, primarily because interventional studies rarely capture the reasons. Objective To examine factors important to older adults who disagree with a deprescribing recommendation given by a primary care physician to a hypothetical patient experiencing polypharmacy. Design, Setting, and Participants This online, vignette-based survey study was conducted from December 1, 2020, to March 31, 2021, with participants 65 years or older in the United Kingdom, the US, Australia, and the Netherlands. The primary outcome of the main study was disagreement with a deprescribing recommendation. A content analysis was subsequently conducted of the free-text reasons provided by participants who strongly disagreed or disagreed with deprescribing. Data were analyzed from August 22, 2022, to February 12, 2023. Main Outcomes and Measures Attitudes, beliefs, fears, and recommended actions of older adults in response to deprescribing recommendations. Results Of the 899 participants included in the analysis, the mean (SD) age was 71.5 (4.9) years; 456 participants (50.7%) were men. Attitudes, beliefs, and fears reported by participants included doubts about deprescribing (361 [40.2%]), valuing medications (139 [15.5%]), and a preference to avoid change (132 [14.7%]). Valuing medications was reported more commonly among participants who strongly disagreed compared with those who disagreed with deprescribing (48 of 205 [23.4%] vs 91 of 694 [13.1%], respectively; P < .001) or had personal experience with the same medication class as the vignette compared with no experience (93 of 517 [18.0%] vs 46 of 318 [12.1%], respectively; P = .02). Participants shared that improved communication (225 [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication preferences (137 [15.2%]) may increase their agreement with deprescribing. Participants who disagreed compared with those who strongly disagreed were more interested in additional communication (196 [28.2%] vs 29 [14.2%], respectively; P < .001), alternative strategies (117 [16.9%] vs 21 [10.2%], respectively; P = .02), or consideration of medication preferences (122 [17.6%] vs 15 [7.3%], respectively; P < .001). Conclusions and Relevance In this survey study, older adults who disagreed with a deprescribing recommendation were more interested in additional communication, alternative strategies, or consideration of medication preferences compared with those who strongly disagreed. These findings suggest that identifying the degree of disagreement with deprescribing could be used to tailor patient-centered communication about deprescribing in older adults.
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Affiliation(s)
- Kristie Rebecca Weir
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jenny Shang
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Jae Choi
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Ruchi Rana
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Sarah E. Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
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Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open 2023; 6:e2336728. [PMID: 37787993 PMCID: PMC10548310 DOI: 10.1001/jamanetworkopen.2023.36728] [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: 02/16/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. Objective To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. Design, Setting, and Participants A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. Main Outcomes and Measures The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. Results A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Conclusions and Relevance Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.
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Affiliation(s)
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Nicole Williams
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia
| | - Matthew K. Wynia
- University of Colorado Center for Bioethics and Humanities, Anschutz Medical Campus, Aurora
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Policy and Management, Colorado School of Public Health, Aurora
| | - Ariel R. Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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18
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks. Clin Ther 2023; 45:947-956. [PMID: 37640614 PMCID: PMC10841554 DOI: 10.1016/j.clinthera.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC. METHODS A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping. FINDINGS Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication. IMPLICATIONS Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Kobi Nathan
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Thomas V Caprio
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; University of Rochester Home Care, University of Rochester Medical Center, Rochester, New York; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, New York
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Pariente A. Use of psychotropic drugs in the elderly in France: Are we condemned to remain at high tide? Therapie 2023; 78:565-573. [PMID: 37012150 DOI: 10.1016/j.therap.2023.03.006] [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: 12/26/2022] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
Psychotropics are widely used drugs, especially in the elderly, especially in France. This, and the risks associated to their use, logically led to concerns that resulted in numerous studies, reports, and regulatory actions intending to limit this use. This review objective was to provide an overview of psychotropic use in elderly subjects in France for antipsychotics, antidepressants, and benzodiazepines and related drugs. The narrative review performed is structured in two parts. The first reminds the initial steps of psychotropic use monitoring in the general French population. The second provides information on psychotropic use in elderly in France using the latest open data released by the French Health Insurance system and processed using the dedicated DrugSurv tool developed within the DRUGS-SAFE® and DRUGS-SAFE® programs. This was completed examining the most recent studies regarding psychotropic use in elderly in France, whether they consisted in publications or reports. At least before the COVID-19 epidemic, decreases in psychotropic prevalence of use among the elderly in France could be observed, mostly for antipsychotics or benzodiazepines (e.g. antipsychotics, 2006-2013: 10.3% decrease and benzodiazepines 2012-2020: decrease from 30.6% to 24.7% in subjects aged ≥65). Psychotropic prevalence of use remained however very high overall (e.g. antidepressants, 2013: 13% in subjects aged 65-74 and 18% in aged ≥65), exceeding that of most other countries, with a significant proportion of inappropriate use (e.g. in 30% of benzodiazepine users, all ages) carrying a clearly identified risks for uncertain benefit. Initiatives have been multiplied at the national level to reduce psychotropic overuse in the elderly. The reported prevalences demonstrate their effectiveness is obviously insufficient. This limited effectiveness is not specific to psychotropics and might reside in a failure to create strong adherence to messages and recommendations. Other levels should be considered, especially regional, for interventions coupled with pharmacoepidemiologic monitoring allowing impact assessment.
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Affiliation(s)
- Antoine Pariente
- Service de pharmacologie médicale, CHU de Bordeaux, université de Bordeaux, zone nord bat 1A, BP 36, 33076 Bordeaux cedex, France.
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20
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Alexopoulos AS, Crowley MJ, Kahkoska AR. Diabetes Medication Changes in Older Adults With Type 2 Diabetes: Insights Into Physician Factors and Questions Ahead. Diabetes Care 2023; 46:1137-1139. [PMID: 37220268 PMCID: PMC10234739 DOI: 10.2337/dci23-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Division of Endocrinology, Department of Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
| | - Matthew J. Crowley
- Division of Endocrinology, Department of Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
| | - Anna R. Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Endocrinology and Metabolism, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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21
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Oktora MP, Yuniar CT, Amalia L, Abdulah R, Hak E, Denig P. Attitudes towards deprescribing and patient-related factors associated with willingness to stop medication among older patients with type 2 diabetes (T2D) in Indonesia: a cross-sectional survey study. BMC Geriatr 2023; 23:21. [PMID: 36635653 PMCID: PMC9835373 DOI: 10.1186/s12877-022-03718-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Deprescribing of preventive medication is recommended in older patients with polypharmacy, including people with type 2 diabetes (T2D). It seems that many patients in low-middle-income countries are not willing to have their medicines deprescribed. This study aims to assess attitudes of Indonesian patients with T2D towards deprescribing in general and regarding specific cardiometabolic medicines, and factors influencing their willingness to stop medicines. METHODS Primary care patients with T2D of ≥60 years in Indonesia completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Attitudes in general and for cardiometabolic medicines were reported descriptively. Proportions of patients willing to stop one or more medicines when recommended by different healthcare professionals were compared with Chi-square test. Multiple regression analysis was used to analyse the influence between patient-related factors and the willingness to stop medicines. RESULTS The survey was completed by 196 participants (median age 69 years, 73% female). The percentages willing to stop medicines were 69, 67, and 41%, when the general practitioner (GP), the specialist, or the pharmacist initiates the process (p-value < 0.001). Higher perceived burden of medicines (p-value = 0.03) and less concerns about stopping (p-value < 0.001) were associated with a higher willingness to stop medicines if proposed by the GP. Patients using multiple glucose-regulating medicines were less willing to stop (p-value = 0.02). Using complementary or alternative medicines was not associated with the willingness to stop. If proposed by their pharmacist, patients without substantial education were more willing to stop than educated patients. CONCLUSIONS Only two-thirds of older people with T2D in Indonesia were willing to stop one or more of their medicines if the GP or specialist recommended this, and even less when the pharmacist proposed this. Attention should be given to concerns about stopping specific medicines, especially among patients using multiple glucose-lowering medicines, who may be more eligible but were less willing to accept deprescribing.
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Affiliation(s)
- Monika Pury Oktora
- grid.4830.f0000 0004 0407 1981University Medical Center Groningen (UMCG), Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Cindra Tri Yuniar
- grid.434933.a0000 0004 1808 0563School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Institut Teknologi Bandung (ITB), Bandung, Indonesia
| | - Lia Amalia
- grid.434933.a0000 0004 1808 0563School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Institut Teknologi Bandung (ITB), Bandung, Indonesia
| | - Rizky Abdulah
- grid.11553.330000 0004 1796 1481Faculty of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Universitas Padjadjaran (UNPAD), Bandung, Indonesia
| | - Eelko Hak
- grid.4830.f0000 0004 0407 1981Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and –Economics, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- grid.4830.f0000 0004 0407 1981University Medical Center Groningen (UMCG), Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
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22
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Bawazeer G, Alsaad S, Almalag H, Alqahtani A, Altulaihi N, Alodhayani A, AlHossan A, Sales I. Impact of Specialized Clinics on Medications Deprescribing in Older Adults: A Pilot Study in Ambulatory Care Clinics in a Teaching Hospital. Saudi Pharm J 2022; 30:1027-1035. [PMID: 35903532 PMCID: PMC9315319 DOI: 10.1016/j.jsps.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
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23
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Barrett R, Hodgkinson J. Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020). Ther Adv Cardiovasc Dis 2022; 16:17539447221137170. [PMID: 36420815 PMCID: PMC9702971 DOI: 10.1177/17539447221137170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 10/19/2022] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours. AIM This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic. METHODS A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest. RESULTS Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications. CONCLUSION A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.
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Affiliation(s)
- Ravina Barrett
- School of Applied Sciences, University of
Brighton, Cockcroft Building, Lewes Road, Moulsecoomb, Brighton BN2 4GJ,
UK
| | - James Hodgkinson
- Murray Learning Centre, Institute of Applied
Health Research, College of Medical and Dental Sciences, University of
Birmingham, Birmingham, UK
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