1
|
Soames J, Pettigrew LM. Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory. BMJ Open 2024; 14:e080546. [PMID: 38816046 PMCID: PMC11141199 DOI: 10.1136/bmjopen-2023-080546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/24/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN Mixed methods systematic review. DATA SOURCES MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER CRD42022341009.
Collapse
Affiliation(s)
- Jamie Soames
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
2
|
Coe A, Abid N, Kaylor-Hughes C. Social media group support for antidepressant deprescribing: a mixed-methods survey of patient experiences. Aust J Prim Health 2024; 30:PY23046. [PMID: 38709900 DOI: 10.1071/py23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
Background Antidepressant use has continually increased in recent decades and although they are an effective treatment for moderate-to-severe depression, when there is no longer a clinical benefit, deprescribing should occur. Currently, routine deprescribing is not part of clinical practice and research shows that there has been an increase in antidepressant users seeking informal support online. This small scoping exercise used a mixed-methods online survey to investigate the motives antidepressant users have for joining social media deprescribing support groups, and what elements of the groups are most valuable to them. Methods Thirty members of two antidepressant deprescribing Facebook groups completed an online survey with quantitative and open-text response questions to determine participant characteristics and motivation for group membership. Quantitative data were analysed using descriptive statistics, and open-text responses were analysed thematically through NVivo. Results Two overarching themes were evident: first, clinician expertise , where participants repeatedly reported a perceived lack of skills around deprescribing by their clinician, not being included in shared decision-making about their treatment, and symptoms of withdrawal during deprescribing going unaddressed. Motivated by the lack of clinical support, peer support developed as the second theme. Here, people sought help online where they received education, knowledge sharing and lived experience guidance for tapering. The Facebook groups also provided validation and peer support, which motivated people to continue engaging with the group. Conclusions Antidepressant users who wish to cease their medication are increasingly subscribing to specialised online support groups due to the lack of information and support from clinicians. This study highlights the ongoing need for such support groups. Improved clinician understanding about the complexities of antidepressant deprescribing is needed to enable them to effectively engage in shared decision-making with their patients.
Collapse
Affiliation(s)
- Amy Coe
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
| | - Noor Abid
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
| | - Catherine Kaylor-Hughes
- Department of General Practice and Primary Care, The University of Melbourne, Medical Bldg (181) Corner Grattan Street & Royal Parade, Melbourne, Vic. 3010, Australia
| |
Collapse
|
3
|
Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
Collapse
Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| |
Collapse
|
4
|
O'Mahoney L, Highton P, Abdala R, Dallosso H, Gillies CL, Ragha S, Munday F, Robinson J, Marshall A, Sheppard JP, Khunti K, Seidu S. Deintensification of potentially inappropriate medications amongst older frail people with type 2 diabetes: Protocol for a cluster randomised controlled trial (D-MED study). Prim Care Diabetes 2024; 18:132-137. [PMID: 38220558 DOI: 10.1016/j.pcd.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/16/2024]
Abstract
AIMS Amongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to 'usual' care at 12-months. METHODS This study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the 'enhanced care' group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified. RESULTS Study recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients). CONCLUSIONS Digital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378.
Collapse
Affiliation(s)
- Lauren O'Mahoney
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Patrick Highton
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK.
| | - Ruksar Abdala
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Helen Dallosso
- University Hospitals of Leicester NHS Trust, Leicester Diabetes Centre, Leicester, UK
| | - Clare L Gillies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Seema Ragha
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Fiona Munday
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - John Robinson
- Primary Care Information Service, University of Nottingham, Nottingham, UK
| | - Andrew Marshall
- Primary Care Information Service, University of Nottingham, Nottingham, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester, UK
| |
Collapse
|
5
|
Jerjes W, Harding D. De-prescribing in primary care: the clinical, ethical and psychological considerations. J Prim Health Care 2024; 16:96-98. [PMID: 38546783 DOI: 10.1071/hc23118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/31/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Waseem Jerjes
- North End Medical Centre, Hammersmith and Fulham Partnership, London, UK; and Research and Development Unit, Hammersmith and Fulham Primary Care Network, London, UK; and Faculty of Medicine, Imperial College, London, UK
| | - Daniel Harding
- North End Medical Centre, Hammersmith and Fulham Partnership, London, UK
| |
Collapse
|
6
|
Demir B, Demir S, Wickens CM, Hoseinzadeh Nooshabadi M, Rodak T, Donmez B. Exploring the Behaviour Change Wheel and the Theoretical Domains Framework in interventions for mobile phone driver distraction: A scoping review. ACCIDENT; ANALYSIS AND PREVENTION 2024; 195:107369. [PMID: 38061292 DOI: 10.1016/j.aap.2023.107369] [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: 12/16/2022] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 12/30/2023]
Abstract
Mobile phone use while driving remains a significant traffic safety concern. Although numerous interventions have been developed to address it, there is a gap in the synthesis of relevant information through a comprehensive behaviour change lens. This scoping review uses the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework (TDF) to examine the literature to (a) identify behavioural constructs targeted in interventions for mobile phone use while driving, (b) determine if the intervention success varied by sociodemographic group (e.g., age, gender, driving experience), and (c) map interventions to TDF domains to highlight areas for future research. Following the PRISMA extension for scoping reviews, we searched seven databases and identified 5,202 articles. After screening, 50 articles detailing 56 studies met the following inclusion criteria: (a) intervention studies, (b) providing details on methods and results, (c) written in English, and (d) targeting any driver behaviour related to mobile phone use while driving with a bottom-up approach, using not regulation or law enforcement, but individuals' psychological processes, such as cognitive, behavioural, and emotional. Findings show that most interventions targeted young drivers and were typically effective. Except for a few studies, the effectiveness of interventions targeting different sociodemographic groups either remained untested or revealed nonsignificant differences. This finding points to a gap in the literature, indicating a need for further investigation into the efficacy of interventions for different groups, and for tailoring and testing them accordingly. The interventions also often targeted multiple TDF domains, complicating the interpretation of the relative efficacy of specific domains. Most frequently targeted domains included beliefs and consequences, emotions, knowledge, social influence, social/professional role and identity, and behavioural regulation. Physical skills and optimism domains were not targeted in any intervention. Further, almost all interventions addressed deliberate engagement in mobile phone distractions, while the automatic and fast processes involved in such behaviours were often overlooked. Mobile phone distractions are in part habitual behaviours, yet the existing mitigation efforts mostly assumed intentional engagement. More focus on the habitual nature of mobile phone distractions is needed.
Collapse
Affiliation(s)
- Basar Demir
- University of Toronto, Department of Mechanical and Industrial Engineering, 5 King's College Road, Toronto, ON M5S 3G8, Canada; Faculty of Arts and Sciences, Final International University, Kyrenia via Mersin 10, Türkiye.
| | - Sila Demir
- Faculty of Arts and Sciences, Final International University, Kyrenia via Mersin 10, Türkiye; Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto ON M5S 2S1, Canada.
| | - Christine M Wickens
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto ON M5S 2S1, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Canada; Dalla Lana School of Public Health, University of Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Canada.
| | - Mehdi Hoseinzadeh Nooshabadi
- University of Toronto, Department of Mechanical and Industrial Engineering, 5 King's College Road, Toronto, ON M5S 3G8, Canada.
| | - Terri Rodak
- CAMH Library, Department of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
| | - Birsen Donmez
- University of Toronto, Department of Mechanical and Industrial Engineering, 5 King's College Road, Toronto, ON M5S 3G8, Canada.
| |
Collapse
|
7
|
Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
Collapse
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
8
|
Thompson W, Reeve E, McDonald EG, Farrell B, Scott S, Steinman MA, Morin L, Lundby C. Ten deprescribing articles you should know about: A guide for newcomers to the field. Basic Clin Pharmacol Toxicol 2023; 133:661-664. [PMID: 37142559 PMCID: PMC10831497 DOI: 10.1111/bcpt.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, SA, Australia
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Barbara Farrell
- Bruyere Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- University of Waterloo School of Pharmacy, Waterloo, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, United Kingdom
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, California, USA
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Inserm CIC 1431, CHU Besançon, Besançon, France
- Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Carina Lundby
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| |
Collapse
|
9
|
Moriarty F, Hughes CM. Deprescribing and medicines optimisation, two sides of the same coin? Considerations for design of interventional studies. Basic Clin Pharmacol Toxicol 2023; 133:665-668. [PMID: 37183267 DOI: 10.1111/bcpt.13900] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/20/2023] [Accepted: 05/11/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | |
Collapse
|
10
|
Scott S, Martin-Kerry J, Bhattacharya D. Developing and testing complex behaviour change interventions to support proactive deprescribing: A narrative review. Basic Clin Pharmacol Toxicol 2023; 133:669-672. [PMID: 36974035 DOI: 10.1111/bcpt.13863] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Sion Scott
- School of Healthcare, University of Leicester, Leicester, LE1 8RH, UK
| | | | - Debi Bhattacharya
- School of Healthcare, University of Leicester, Leicester, LE1 8RH, UK
| |
Collapse
|
11
|
Vidonscky Lüthold R, Henz NC, Fuhrer C, Häner A, Schenk M, Jungo KT, Streit S. Inappropriate proton-pump inhibitor prescribing in primary care - an observational study with quality circles. Swiss Med Wkly 2023; 153:40119. [PMID: 37769322 DOI: 10.57187/smw.2023.40119] [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: 09/30/2023] Open
Abstract
INTRODUCTION Proton-pump inhibitors (PPIs) should be deprescribed when an indication is lacking or the dose is too high. Academic and media reports have tried to raise awareness and thereby reduce the inappropriate prescribing of PPIs. However, pharmacoepidemiologic studies have shown an unchanged frequency of such inappropriate prescribing over time. Little is known about whether or how general practitioners (GPs) adapt their prescribing practices once their awareness of inappropriate PPI prescribing has been raised. OBJECTIVE We aimed to investigate the prevalence of potentially inappropriate PPI prescribing (too high dose or no indication) in a consecutive sample of patients in Swiss primary care settings. Our goal was then to evaluate how GPs managed the patients with potentially inappropriate PPI prescribing over 12 months after flagging these patients. METHODS In this observational study, 11 GPs from the canton of Bern in Switzerland used their medical records to identify 20 patients who had been prescribed a PPI for ≥8 weeks and flagged potentially inappropriate PPI prescribing in their records. After 12 months, we asked the same GPs whether the PPI prescriptions of those patients had changed and, if so, how. RESULTS Of 1,376 patients consecutively screened, 206 (15%) had been prescribed a PPI for ≥8 weeks. Of these 206 patients, 85 (41%) had a potentially inappropriate PPI prescription. Of these 85 patients, 55 (65%) had no indication for PPI, and 30 (35%) had a too-high dose. After one year, only 29 (35%) of the 84 flagged potentially inappropriate PPIs were stopped or reduced. The most frequently mentioned reasons that deprescribing was not possible were a lack of discussion with the patient (no contact or no time), the presence of symptoms requiring the PPI, or the unwillingness of the patient to deprescribe. CONCLUSION In the Swiss primary care setting, the rate of potentially inappropriate PPI prescribing is high. Having GPs flag potentially inappropriate PPI prescribing did not result in PPI deprescribing in most patients over 12 months. Our findings suggest that more personalised and targeted interventions are necessary to successfully implement the deprescribing of potentially inappropriate PPIs. We see the need to co-design interventions with patients and providers and test behavioural change techniques to enable the deprescribing of inappropriate PPIs.
Collapse
Affiliation(s)
- Renata Vidonscky Lüthold
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| |
Collapse
|
12
|
Scott S, Atkins B, Martin-Kerry JM, Pritchard M, Alldred DP, Clark AB, Colles A, Hammond A, Murphy K, Keevil VL, Kellar I, Patel M, Sims E, Taylor J, Turner D, Witham M, Wright D, Bhattacharya D. CompreHensive geriAtRician-led MEdication Review (CHARMER): protocol for a feasibility study of a hospital deprescribing behaviour change intervention. BMJ Open 2023; 13:e075795. [PMID: 37541754 PMCID: PMC10407388 DOI: 10.1136/bmjopen-2023-075795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Over 50% of older adults are prescribed a medicine where the risk of harm outweighs the chances of benefit. During a hospital admission, older adults and carers expect medicines to be reviewed for appropriateness and any inappropriate medicines proactively deprescribed. While the principle of proactive deprescribing is an expectation of good prescribing practice, it is yet to become routine. The CompreHensive geriAtRician-led MEdication Review (CHARMER) study aims to develop and test a five-component behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. This study aims to test the feasibility and acceptability of study processes and CHARMER implementation. METHODS AND ANALYSIS A two-arm purposive allocation feasibility study is being undertaken at four acute hospitals in England, UK (three intervention and one control). The target sample is 400 patients across all hospitals. Primary outcome measures are: (1) participant recruitment rate and (2) participant attrition rate. Secondary outcome measures are: (1) hospital readmission rate; (2) mortality rate and (3) quality of life. Quantitative data will be checked for completeness and quality, and practitioner and patient demographics descriptively analysed. We will undertake a rapid qualitative analysis on observations, interviews and study meeting minutes data. A subsequent thematic analysis will be undertaken with codes mapped to the Theoretical Domains Framework and Normalisation Process Theory. Triangulation of qualitative and quantitative data will be undertaken. ETHICS AND DISSEMINATION Ethics approval was obtained from Wales Research Ethics Committee 1 (IRAS ID 312494) and study approval from the Health Research Authority (22/WA/0087). Informed consent will be sought from all hospital staff involved in data collection activities and for patients involved in enhanced data collection activities. The findings of this study will be disseminated in peer-reviewed journals and conference presentations. TRIAL REGISTRATION ISRCTN11899506.
Collapse
Affiliation(s)
- Sion Scott
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Bethany Atkins
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Megan Pritchard
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Antony Colles
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amber Hammond
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Katherine Murphy
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Victoria L Keevil
- Department of Medicine for the Elderly, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ian Kellar
- Department of Psychology, The University of Sheffield, Sheffield, UK
| | - Martyn Patel
- Norwich Medical School, University of East Anglia, Norwich, UK
- Older People's Medicine Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Erika Sims
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miles Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
- AGE Research Group, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - David Wright
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
- School of Pharmacy, University of Bergen, Bergen, Norway
| | - Debi Bhattacharya
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
13
|
Coteur K, Van Nuland M, Schoenmakers B, Van den Broeck K, Anthierens S. "At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users. Heliyon 2023; 9:e16215. [PMID: 37234622 PMCID: PMC10205632 DOI: 10.1016/j.heliyon.2023.e16215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/07/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Background Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. Aim Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and setting A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. Method Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. Results The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. Conclusion Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.
Collapse
Affiliation(s)
- Kristien Coteur
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Belgium
| | - Marc Van Nuland
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Belgium
| | - Birgitte Schoenmakers
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, Belgium
| | - Kris Van den Broeck
- Department of Family Medicine and Population Health, University of Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Belgium
| |
Collapse
|
14
|
Batcup C, Breth-Petersen M, Dakin T, Barratt A, McGain F, Newell BR, Pickles K. Behavioural change interventions encouraging clinicians to reduce carbon emissions in clinical activity: a systematic review. BMC Health Serv Res 2023; 23:384. [PMID: 37081553 PMCID: PMC10116654 DOI: 10.1186/s12913-023-09370-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Clinical activity accounts for 70-80% of the carbon footprint of healthcare. A critical component of reducing emissions is shifting clinical behaviour towards reducing, avoiding, or replacing carbon-intensive healthcare. The objective of this systematic review was to find, map and assess behaviour change interventions that have been implemented in healthcare settings to encourage clinicians to reduce greenhouse gas emissions from their clinical activity. METHODS Studies eligible for inclusion were those reporting on a behaviour change intervention to reduce carbon emissions via changes in healthcare workplace behaviour. Six databases were searched in November 2021 (updated February 2022). A pre-determined template was used to extract data from the studies, and risk of bias was assessed. The behaviour change techniques (BCTs) used in the interventions were coded using the BCT Taxonomy. RESULTS Six full-text studies were included in this review, and 14 conference abstracts. All studies used a before-after intervention design. The majority were UK studies (n = 15), followed by US (n = 3) and Australia (n = 2). Of the full-text studies, four focused on reducing the emissions associated with anaesthesia, and two aimed at reducing unnecessary test ordering. Of the conference abstracts, 13 focused on anaesthetic gas usage, and one on respiratory inhalers. The most common BCTs used were social support, salience of consequences, restructuring the physical environment, prompts and cues, feedback on outcome of behaviour, and information about environmental consequences. All studies reported success of their interventions in reducing carbon emissions, prescribing, ordering, and financial costs; however, only two studies reported the magnitude and significance of their intervention's success. All studies scored at least one item as unclear or at risk of bias. CONCLUSION Most interventions to date have targeted anaesthesia or pathology test ordering in hospital settings. Due to the diverse study outcomes and consequent inability to pool the results, this review is descriptive only, limiting our ability to conclude the effectiveness of interventions. Multiple BCTs were used in each study but these were not compared, evaluated, or used systematically. All studies lacked rigour in study design and measurement of outcomes. REVIEW REGISTRATION The study was registered on Prospero (ID number CRD42021272526) (Breth-Petersen et al., Prospero 2021: CRD42021272526).
Collapse
Affiliation(s)
- Carys Batcup
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Matilde Breth-Petersen
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Thomas Dakin
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Alexandra Barratt
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Forbes McGain
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
- Western Health, Department of Critical Care Medicine, University of Melbourne, Melbourne, Australia
| | - Ben R Newell
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Kristen Pickles
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia.
| |
Collapse
|
15
|
Bužančić I, Ortner Hadžiabdić M. Differences in Factors Influencing Deprescribing between Primary Care Providers: Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4957. [PMID: 36981865 PMCID: PMC10049550 DOI: 10.3390/ijerph20064957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
Deprescribing is a notable approach to improve medication management, but few healthcare systems recognize it. To introduce a new practice, it is important to examine the factors influencing the provision of a new or elaborate cognitive service within the desired setting. This study explores the perceived barriers and facilitators of deprescribing by primary healthcare providers, and identifies the factors associated with a willingness to suggest deprescribing. A cross-sectional survey was conducted (in Croatia, between October 2021 and January 2022) using a validated comprehensive healthcare providers' opinions, preferences, and attitudes towards deprescribing (CHOPPED) questionnaire. A total of 419 pharmacists and 124 physicians participated. Participants showed a high willingness to deprescribe, with significantly higher scores in physicians than in pharmacists (5.00 (interquartile range-IQR 5-5) vs. 4.00 (IQR 4-5), p < 0.001). Pharmacists had significantly higher scores in seven out of ten factors (knowledge, awareness, collaboration facilitators, competencies facilitators, healthcare system facilitators, collaboration barriers, competencies barriers) while in the remaining three factors (patient facilitators, patient and healthcare system barriers) there was no difference in scores. The strongest positive correlation with willingness to suggest deprescribing was found with the collaboration and healthcare system facilitators factors for pharmacists (G = 0.331, p < 0.001, and G = 0.309, p < 0.001, respectively), and with knowledge, awareness, and patient facilitators factors for physicians (G = 0.446, p = 0.001; G = 0.771, p < 0.001; and G = 0.259, p = 0.043, respectively). Primary healthcare providers are willing to suggest deprescribing but face different barriers and facilitators. For pharmacists, the most important facilitators were extrinsic, while for physicians they were more intrinsic and patient related. The stated results provide target areas which one could focus upon to help to engage healthcare providers in deprescribing.
Collapse
Affiliation(s)
- Iva Bužančić
- Faculty of Pharmacy and Biochemistry, University of Zagreb, A. Kovačića 1, 10 000 Zagreb, Croatia
- City Pharmacies Zagreb, Kralja Držislava 6, 10 000 Zagreb, Croatia
| | - Maja Ortner Hadžiabdić
- Faculty of Pharmacy and Biochemistry, University of Zagreb, A. Kovačića 1, 10 000 Zagreb, Croatia
| |
Collapse
|
16
|
Farrell B, Rousse-Grossman J, Santamaria C, McCarthy LM. Applying the Behaviour Change Wheel to support deprescribing in long-term care: Qualitative interviews with stakeholder participants. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100256. [PMID: 37091629 PMCID: PMC10113898 DOI: 10.1016/j.rcsop.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Background Implementation and behavioural science are increasingly being used to support development and translation of evidence-based interventions into practice. We used the Behaviour Change Wheel (BCW) approach in two stakeholder forums to identify target behaviours and supporting actions to inform the development of a framework to support deprescribing in long-term care homes. During our planning for these forums, we found many applications of the BCW approach used in healthcare. However, we found no accounts of stakeholders' experiences when the BCW approach was used with large groups of people who were mostly unfamiliar with behavioural science. Objective The goal of this research was to gain insight into the use of the BCW approach in the context of developing a framework to support deprescribing in long-term care. Methods This descriptive qualitative study employed one-on-one semi-structured interviews with Ontario long-term care stakeholders who had participated in one or both of two in-person forums that we hosted. Interviews were transcribed verbatim and an inductive content-analysis approach was used to code data and determine themes. Results Fifteen interviews were conducted. Four themes were identified. First, the BCW was new and made sense, but people found it hard to identify target behaviours before planning solutions. Second, participants varied in their opinions as to whether the 'right' people were participating. Third, participants found that the forum activities, worksheets and facilitators helped people use the approach. Fourth, stakeholder perspectives about potential implementation challenges and strategies to maximize success were identified. Conclusions Overall, participants were positive about the use of the BCW approach, however, its usefulness could be optimized by enhancing explanations, facilitation and logistics to ensure an initial focus on targeting behaviours. Making stakeholder perspectives transparent and ensuring mechanisms are present to ensure all views are sought and considered are also important to optimizing participant experience.
Collapse
|
17
|
Zhang Y, Wilkins JM, Bessette LG, York C, Wong V, Lin KJ. Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization. JAMA Netw Open 2023; 6:e230063. [PMID: 36800180 PMCID: PMC9938426 DOI: 10.1001/jamanetworkopen.2023.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
Importance There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults. Objective To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults. Design, Setting, and Participants This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022. Exposures New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc). Main Outcomes and Measures The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used. Results Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs. Conclusions and Relevance The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.
Collapse
Affiliation(s)
- Yichi Zhang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent Wong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
18
|
O'Brien K, Burke R, Karlawish J. A Roadmap for Modifying Clinician Behavior to Improve the Detection of Cognitive Impairment. J Gen Intern Med 2023; 38:508-512. [PMID: 36163531 PMCID: PMC9905516 DOI: 10.1007/s11606-022-07824-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/16/2022] [Indexed: 11/29/2022]
Abstract
A staggering number of individuals live with cognitive decline. Primary care providers are ideally situated to detect the first signs of cognitive decline, but many persons remain undiagnosed. This limits their access to appropriate care. Unfortunately, the timely diagnosis of mild cognitive impairment or dementia in primary care is difficult to achieve. There is a great need for interventions to address this problem. This article applies an implementation science framework, the Behavioral Change Wheel, to evaluate the factors that influence detection of cognitive impairment in primary care and proposes candidate interventions for future study.
Collapse
Affiliation(s)
- Kyra O'Brien
- Department of Neurology, Perelman School of Medicine, Penn Memory Center, University of Pennsylvania, Philadelphia, PA, USA. kyra.o'
| | - Robert Burke
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jason Karlawish
- Departments of Medicine, Medical Ethics and Health Policy, and Neurology, Perelman School of Medicine, Penn Memory Center, University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
19
|
Linsky AM, Kressin NR, Stolzmann K, Pendergast J, Rosen AK, Bokhour BG, Simon SR. Direct-to-consumer strategies to promote deprescribing in primary care: a pilot study. BMC PRIMARY CARE 2022; 23:53. [PMID: 35317734 PMCID: PMC8939089 DOI: 10.1186/s12875-022-01655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022]
Abstract
Background Deprescribing, or the intentional discontinuation or dose-reduction of medications, is an approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications. Methods We conducted a pre-post pilot trial, using an historical control group, at an urban VA medical center. We included patients in one of two cohorts: 1) chronic proton pump inhibitor users (PPI), defined as use of any dose for 90 consecutive days, or 2) patients at hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c < 7%; and age ≥ 65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome. Results The 348 subjects (253 intervention, 95 historical control) were primarily age ≥ 65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p = 0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p = 0.001). Conclusions Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method associated with increases in both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the potential for patients to initiate deprescribing discussions within clinical encounters is a promising strategy to reduce drug burden and decrease adverse drug effects and harms.
Collapse
|
20
|
A Need for Benzodiazepine Deprescribing in the COVID-19 Pandemic: A Cohort Study. PHARMACY 2022; 10:pharmacy10050120. [PMID: 36287441 PMCID: PMC9611451 DOI: 10.3390/pharmacy10050120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
The COVID-19 pandemic has had a negative impact on patients’ mental health. The aim of this study was to explore whether the pandemic influenced the use and prescription of benzodiazepines and increased the need for community pharmacist involvement in counselling on deprescribing. Electronic prescription-related data from one pharmacy in Croatia were retrospectively collected for the COVID-19 period (April 2020 to March 2021) and compared with pre-COVID-19 (April 2019 to March 2020) data. Data were collected for patients diagnosed with anxiety disorders who filled out more than one prescription for benzodiazepines, and included age, sex, number of medicines, benzodiazepines, and comorbidities. A total of 1290 benzodiazepine users were identified; of these, 32.87% started using benzodiazepines during the COVID-19 period, while 35.2% continued with benzodiazepine use. More than half of all benzodiazepine users were identified as potential deprescribing candidates (dispensed more than three prescriptions). Women, older patients, multimorbid individuals, and patients with polypharmacy were more likely to use benzodiazepines for a prolonged period. The results show a negative trend of benzodiazepine usage among community-dwelling patients during the pandemic. Community pharmacists can identify potential candidates for deprescribing and initiate a process that ensures more rational use of benzodiazepines and increases the safety of treatment.
Collapse
|
21
|
Evrard P, Pétein C, Beuscart JB, Spinewine A. Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework. Implement Sci 2022; 17:41. [PMID: 35804428 PMCID: PMC9264665 DOI: 10.1186/s13012-022-01206-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Many strategies aimed at deprescribing benzodiazepine receptor agonists (BZRA) in older adults have already been evaluated with various success rates. There is so far no consensus on which strategy components increase deprescribing the most. Yet, despite an unfavourable benefit-to-risk ratio, BZRA use among older adults remains high. We systematically reviewed barriers and enablers for BZRA deprescribing in older adults. Methods Two reviewers independently screened records identified from five electronic databases—Medline, Embase, PsycINFO, CINAHL and the Cochrane library—and published before October 2020. They searched for grey literature using Google Scholar. Qualitative and quantitative records reporting data on the attitudes of older adults, caregivers and healthcare providers towards BZRA deprescribing were included. Populations at the end of life or with specific psychiatric illness, except for dementia, were excluded. The two reviewers independently assessed the quality of the included studies using the mixed-methods appraisal tool. Barriers and enablers were identified and then coded into domains of the theoretical domains framework (TDF) using a combination of deductive and inductive qualitative analysis. The most relevant TDF domains for BZRA deprescribing were then identified. Results Twenty-three studies were included 13 quantitative, 8 qualitative and 2 mixed-method studies. The points of view of older adults, general practitioners and nurses were reported in 19, 9 and 3 records, respectively. We identified barriers and enablers in the majority of TDF domains and in two additional themes: “patient characteristics” and “BZRA prescribing patterns”. Overall, the most relevant TDF domains were “beliefs about capabilities”, “beliefs about consequences”, “environmental context and resources”, “intention”, “goals”, “social influences”, “memory, attention and decision processes”. Perceived barriers and enablers within domains differed across settings and across stakeholders. Conclusion The relevant TDF domains we identified can now be linked to behavioural change techniques to help in the design of future strategies and health policies. Future studies should also assess barriers and enablers perceived by under-evaluated stakeholders (such as pharmacists, psychiatrists and health care professionals in the hospital setting). Trial registration This work was registered on PROSPERO under the title “Barriers and enablers to benzodiazepine receptor agonists deprescribing”. Registration number: CRD42020213035 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01206-7.
Collapse
Affiliation(s)
- Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.
| | - Catherine Pétein
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.,Pharmacy Department, CHU UCL Namur, Yvoir, Belgium
| |
Collapse
|
22
|
Bai I, Isenor JE, Reeve E, Whelan AM, Martin-Misener R, Burgess S, Kennie-Kaulbach N. Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs. Res Social Adm Pharm 2021; 18:3350-3357. [PMID: 34895842 DOI: 10.1016/j.sapharm.2021.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. OBJECTIVES To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. METHODS Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. RESULTS Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. CONCLUSIONS This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.
Collapse
Affiliation(s)
- Isaac Bai
- Faculty of Medicine, Dalhousie University, 5849 University Ave, Halifax, NS, Canada
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
| | - Sarah Burgess
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
| | | |
Collapse
|
23
|
Tang JY, Lun P, Teng PHJ, Ang W, Tan KT, Ding YY. Intervention elements and behavior change techniques to improve prescribing for older adults with multimorbidity in Singapore: a modified Delphi study. Eur Geriatr Med 2021; 13:531-539. [PMID: 34647238 DOI: 10.1007/s41999-021-00566-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Potentially inappropriate prescribing among older adults is a rising concern, attributed mainly by polypharmacy and multimorbidity. We aimed to identify key components and strategies for construction of a context-relevant intervention to facilitate appropriate prescribing in outpatient clinics in Singapore. METHODS The modified Delphi study was conducted in two rounds with 20 geriatricians from seven public hospitals in Singapore. Round one survey presented 69 statements formulated from a scoping review, while round two presented 23 statements with some modifications based on round one comments. The statements were rated against a 7-point Likert scale on their importance and impact on prescribing for older adults with multimorbidty. RESULTS Consensus were achieved for 90% of the statements. Seven intervention elements were identified as being important: medication review, training, medication therapy management, shared decision making, patient interview, medication reconciliation, comprehensive geriatric assessment. In addition, some commonly identified behavior change techniques included goal setting (behavior), goal setting (outcome) and problem solving. CONCLUSIONS This study identified important intervention elements and their potential strategies that could be adopted in an intervention to optimize appropriate prescribing for older adults with multimorbidity.
Collapse
Affiliation(s)
- Jia Ying Tang
- Geriatric Education and Research Institute Limited, 2 Yishun Central 2, Singapore, 768024, Singapore.
| | - Penny Lun
- Geriatric Education and Research Institute Limited, 2 Yishun Central 2, Singapore, 768024, Singapore
| | - Poh Hoon June Teng
- Geriatric Education and Research Institute Limited, 2 Yishun Central 2, Singapore, 768024, Singapore
| | - Wendy Ang
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Keng Teng Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute Limited, 2 Yishun Central 2, Singapore, 768024, Singapore
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| |
Collapse
|
24
|
Mohamed Ibrahim O, Al Mazrouei N, Al Meslamani AZ, Kassem AB, El-Bassiouny NA, Mohammed Ebaed SB, Ibrahim RM. Assessment of a new strategy for catalyzing deprescribing in community pharmacies. J Am Pharm Assoc (2003) 2021; 62:125-133. [PMID: 34580032 DOI: 10.1016/j.japh.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although community pharmacists have been actively engaged in patient care, their role in deprescribing is still restricted. OBJECTIVES This study aimed to assess the effectiveness of a new educational approach designed to catalyze deprescribing in community pharmacies. METHODS In this 4-month, randomized, controlled trial, 108 community pharmacies in Egypt were randomly and equally distributed to either the active or the control groups. Participants from the active group pharmacies received 31 deprescribing-related clinical case scenarios, designed according to the available deprescribing guideline and clinical experiences of an expert panel members, and delivered through WhatsApp. Then participants from both groups reported the incidence of potentially inappropriate medicines (PIMs), the frequency of deprescribing opportunities, and related pharmacist interventions. RESULTS Pharmacists from the active group reported a considerably higher incidence of PIMs (20.87%) than that reported by pharmacists from the control group (5.03%). In addition, they made 1326 deprescribing-related interventions, of which 1022 (77.07%) were accepted and 641 (48.34%) were significant interventions. The proportions of cessation of drug therapy, reducing the dose, and persuasion of patients to accept deprescribing pharmacist interventions in the active group were 37.85%, 22.09%, and 10.63%, respectively. In contrast, 150 of 268 deprescribing-related interventions (55.97%) in the active group were accepted. The clinical value and type of deprescribing decision were statistically significant determinants for the acceptance of deprescribing decisions. The mean time needed to persuade the patient about deprescribing and the cost saved per patient across the active and the control groups were 5.09 ± 3.54 minutes versus 10.03 ± 6.19 minutes and 17.88 ± 9.60 U.S. dollars versus 4.49 ± 2.44 U.S. dollars, respectively. CONCLUSION The intervention proposed improved the frequency and clinical value of deprescribing decisions.
Collapse
|
25
|
Coe A, Kaylor-Hughes C, Fletcher S, Murray E, Gunn J. Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review. BMJ Open 2021; 11:e052547. [PMID: 34489296 PMCID: PMC8422486 DOI: 10.1136/bmjopen-2021-052547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing. SETTING Primary care. DATA SOURCES Medline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021. STUDY SELECTION Included studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations. DATA EXTRACTION Screening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles. RESULTS Fifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added. CONCLUSION Activities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.
Collapse
Affiliation(s)
- Amy Coe
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Murray
- Primary Care and Population Health, University College London, London, UK
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Thompson W, Reeve E. Deprescribing: Moving beyond barriers and facilitators. Res Social Adm Pharm 2021; 18:2547-2549. [PMID: 33867278 DOI: 10.1016/j.sapharm.2021.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
Unnecessary polypharmacy continues to be a problem among older adults. The field of deprescribing (planned, supervised process of medication discontinuation) aims to address this problem. Deprescribing is a relatively new field despite having grown substantially in recent years. Much of the early research in this area focused on identifying barriers to and facilitators of deprescribing in clinical practice, which contributed to a large body of work on this topic. However, with continuing research around barriers and facilitators, we need to be mindful to undertake research that builds on existing knowledge, addresses known gaps, and advances the field. Additionally, there is a need in deprescribing research to shift focus to developing ways to address known barriers and harness knowledge of facilitators. That is, translating existing knowledge into strategies and tools that can impact clinical practice and lead to practical and sustained deprescribing efforts.
Collapse
Affiliation(s)
- Wade Thompson
- Women's College Research Institute, Toronto, Ontario, Canada; Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark; Hospital Pharmacy Fyn, Odense University Hospital, Odense, Denmark.
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia; Geriatric Medicine Research, Faculty of Medicine, College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| |
Collapse
|