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Winslow KR, Wiggins P. Improved Patient Engagement and Cost Savings Through a Novel Medication Review Process. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024; 30:S116-S118. [PMID: 39041745 DOI: 10.1097/phh.0000000000001978] [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: 07/24/2024]
Abstract
Pharmacist-led interventions are pivotal in identifying and resolving potential adverse drug events (pADEs) while enhancing blood pressure control and medication adherence through educational and counseling interventions. This practice brief outlines the outcomes of the Blue Bag Initiative (BBI), which enhanced pharmacist-led comprehensive medication reviews (CMRs) across community pharmacies in Virginia under Center for Disease Control Cooperative Agreement NU58DP006535. BBI yielded a rate of 131.6 pADEs identified per 100 participants and demonstrated cost savings of 1 to 3 million dollars for the health care system. This report underscores the significance of a standardized, pharmacist-led CMR as integral to interdisciplinary team-based care models within physician practices, facilitating medication therapy management implementation. Enhanced CMR can improve cardiovascular health outcomes while reducing health care expenditures by augmenting patient engagement and medication adherence. This study thus highlights the efficacy and potential of pharmacist-led interventions in increasing access to and optimizing patient care.
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Affiliation(s)
- Karen R Winslow
- Virginia Pharmacists Association, Richmond, Virginia (Dr Winslow); and Virginia Department of Health, Richmond, Virginia (Mr Wiggins)
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2
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Roncal-Belzunce V, Gutiérrez-Valencia M, Leache L, Saiz LC, Bell JS, Erviti J, Martínez-Velilla N. Systematic review and meta-analysis on the effectiveness of multidisciplinary interventions to address polypharmacy in community-dwelling older adults. Ageing Res Rev 2024; 98:102317. [PMID: 38692414 DOI: 10.1016/j.arr.2024.102317] [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: 11/26/2023] [Revised: 03/31/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
Interventions to address polypharmacy in community-dwelling older adults often focus on medication-related outcomes. The aim was to explore the impact of multidisciplinary interventions to manage polypharmacy on clinical outcomes for community-dwelling older adults. This systematic review and meta-analysis included randomized controlled trials (RCTs) on interventions by at least a pharmacist and a physician, indexed in MEDLINE, EMBASE or CENTRAL up to January 2023. Evidence certainty was assessed using the GRADE approach. Seventeen RCTs were included. Fifteen were rated as 'high' risk of bias. No relevant benefits were found in functional and cognitive status (primary outcomes), falls, mortality, quality of life, patient satisfaction, hospital admissions, emergency department or primary care visits. Interventions reduced medication costs, improved medication appropriateness (odds ratio [OR] 0.39), reduced number of medications (mean difference [MD] -0.57), resolved medication-related problems (MD -0.45), and improved medication adherence (relative risk [RR] 1.14). There was a low or very low certainty of the evidence for most outcomes. Multidisciplinary interventions to address polypharmacy appear effective in improving multiple dimensions of medication use. However, evidence for corresponding improvements in functional or cognitive status is scarce. New efficient models of multidisciplinary interventions to address polypharmacy impacting clinical outcomes should be explored.
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Affiliation(s)
- Victoria Roncal-Belzunce
- Public University of Navarre (UPNA), Pamplona, Navarre, Spain; Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain.
| | - Marta Gutiérrez-Valencia
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain.
| | - Leire Leache
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain.
| | - Luis Carlos Saiz
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain.
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.
| | - Juan Erviti
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain.
| | - Nicolás Martínez-Velilla
- Public University of Navarre (UPNA), Pamplona, Navarre, Spain; Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Hospital Universitario de Navarra (HUN)- Navarrabiomed, Pamplona, Navarre, Spain.
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3
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Kelly WN, Ho MJ, Smith T, Bullers K, Bates DW, Kumar A. Association of Pharmacist Interventions With Adverse Drug Events and Potential Adverse Drug Events. Pharmacoepidemiol Drug Saf 2024; 33:e5853. [PMID: 38973415 DOI: 10.1002/pds.5853] [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: 01/04/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Adverse drug events (ADEs) are a frequent cause of injury in patients. Our aim was to assess whether pharmacist interventions compared with no pharmacist intervention results in reduced ADEs and potential adverse drug events (PADEs). METHODS We searched MEDLINE, Embase, and two other databases through September 19, 2022 for any RCT assessing the effect of a pharmacist intervention compared with no pharmacist intervention and reporting on ADEs or PADEs. The risk of bias was assessed using the Cochrane tool for RCTs. A random-effects model was used to pool summary results from individual RCTs. RESULTS Fifteen RCTs met the inclusion criteria. The pooled results showed a statistically significant reduction in ADE associated with pharmacist intervention compared with no pharmacist intervention (RR = 0.86; [95% CI 0.80-0.94]; p = 0.0005) but not for PADEs (RR = 0.79; [95% CI 0.47-1.32]; p = 0.37). The heterogeneity was insignificant (I2 = 0%) for ADEs and substantial (I2 = 77%) for PADEs. Patients receiving a pharmacist intervention were 14% less likely for ADE than those who did not receive a pharmacist intervention. The estimated number of patients needed to prevent one ADE across all patient locations was 33. CONCLUSIONS To our knowledge, this is the first systematic review and meta-analysis of RCTs seeking to understand the association of pharmacist interventions with ADEs and PADEs. The risk of having an ADE is reduced by a seventh for patients receiving a pharmacist care intervention versus no such intervention. The estimated number of patients needed to be followed across all patient locations to prevent one preventable ADE across all patient locations is 33.
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Affiliation(s)
- W N Kelly
- Taneja College of Pharmacy, University of South Florida, Tampa, Florida, USA
| | - M J Ho
- Taneja College of Pharmacy, University of South Florida, Tampa, Florida, USA
| | - T Smith
- Research Methodology and Biostatistics Core, Office of Research, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - K Bullers
- Shimberg Library, USF Health, University of South Florida, Tampa, Florida, USA
| | - D W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - A Kumar
- Research Methodology and Biostatistics Core, Office of Research, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Ramos VH, Hayes L, Simmons K, Trudeau B, Boka A. Pharmacist-Led Deprescribing of Aspirin in Older People in an Outpatient Setting. Sr Care Pharm 2024; 39:212-217. [PMID: 38803027 DOI: 10.4140/tcp.n.2024.212] [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: 05/29/2024]
Abstract
Background In 2019, the American College of Cardiology and American Heart Association updated their joint guidelines stating low-dose aspirin should not be used on a routine basis for primary prevention of atherosclerotic cardiovascular disease (ASCVD) among people older than 70 years of age because of increased bleeding risk.1 In addition to these updated guidelines, a statement released by the US Preventive Services Task Force in April 2022 recommends against the initiation of low-dose aspirin for primary prevention of cardiovascular disease in people 60 years of age or older.² Despite these updated recommendations, aspirin continues to be a common medication older patients take, providing an opportunity for a clinical pharmacist deprescribing intervention. Objective To identify the role of a pharmacist-led aspirin deprescribing intervention within a safety-net health system in the outpatient setting. Methods This project included patients 70 years of age and older who had aspirin listed as an active medication without documented ASCVD. This project assessed aspirin deprescribing rates, time spent on pharmacist outreach, and reasons for patient and/or provider refusal to discontinue aspirin. Results One hundred thirty-one eligible patients were contacted. Of those, 78 (60%) patients discontinued aspirin after speaking with the pharmacist, and 8 patients discontinued aspirin after a clinical pharmacist recommendation to the patient's primary care provider (PCP). The median time spent on outreach was approximately eight minutes. Of the 6 patients who consented to the project but declined to discontinue aspirin therapy based on pharmacist intervention, 5 preferred to discuss the issue with their PCP, while 1 patient was told by an outside provider to take aspirin. Conclusion Results indicate the successful impact a clinical pharmacist may have in deprescribing aspirin in a high-risk population. These data may also suggest that an active and intentional approach to deprescribing is likely to be more effective than a written recommendation to providers.
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Affiliation(s)
| | - Laura Hayes
- 1 Ambulatory Care Pharmacy Specialist, Denver Health Medical Center, Denver, Colorado
| | - Kayley Simmons
- 1 Ambulatory Care Pharmacy Specialist, Denver Health Medical Center, Denver, Colorado
| | | | - Adrian Boka
- 1 Ambulatory Care Pharmacy Specialist, Denver Health Medical Center, Denver, Colorado
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Alkanj A, Godet J, Johns E, Gourieux B, Michel B. Deep learning application to automated classification of recommendations made by hospital pharmacists during medication prescription review. Am J Health Syst Pharm 2024; 81:e296-e303. [PMID: 38294025 DOI: 10.1093/ajhp/zxae011] [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: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Recommendations to improve therapeutics are proposals made by pharmacists during the prescription review process to address suboptimal use of medicines. Recommendations are generated daily as text documents but are rarely reused beyond their primary use to alert prescribers and caregivers. If recommendation data were easier to summarize, they could be used retrospectively to improve safeguards for better prescribing. The objective of this work was to train a deep learning algorithm for automated recommendation classification to valorize the large amount of recommendation data. METHODS The study was conducted in a French university hospital, at which recommendation data were collected throughout 2017. Data from the first 6 months of 2017 were labeled by 2 pharmacists who assigned recommendations to 1 of the 29 possible classes of the French Society of Clinical Pharmacy classification. A deep neural network classifier was trained to predict the class of recommendations. RESULTS In total, 27,699 labeled recommendations from the first half of 2017 were used to train and evaluate a classifier. The prediction accuracy calculated on a validation dataset was 78.0%. We also predicted classes for unlabeled recommendations collected during the second half of 2017. Of the 4,460 predictions reviewed, 67 required correction. When these additional labeled data were concatenated with the original dataset and the neural network was retrained, accuracy reached 81.0%. CONCLUSION To facilitate analysis of recommendations, we have implemented an automated classification system using deep learning that achieves respectable performance. This tool can help to retrospectively highlight the clinical significance of daily medication reviews performed by hospital clinical pharmacists.
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Affiliation(s)
- Ahmad Alkanj
- Laboratoire de Pharmacologie et Toxicologie NeuroCardiovasculaire UR7296, Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique, Centre de Recherche en Biomédecine de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Julien Godet
- ICube-IMAGeS, UMR 7357, Université de Strasbourg, Strasbourg, and Groupe Méthodes Recherche Clinique, Pôle de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Erin Johns
- Laboratoire de Pharmacologie et Toxicologie NeuroCardiovasculaire UR7296, Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique, Centre de Recherche en Biomédecine de Strasbourg, Université de Strasbourg, Strasbourg, and ICube-IMAGeS, UMR 7357, Université de Strasbourg, Strasbourg, France
| | - Bénédicte Gourieux
- Laboratoire de Pharmacologie et Toxicologie NeuroCardiovasculaire UR7296, Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique, Centre de Recherche en Biomédecine de Strasbourg, Université de Strasbourg, Strasbourg, and Service de Pharmacie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Bruno Michel
- Laboratoire de Pharmacologie et Toxicologie NeuroCardiovasculaire UR7296, Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique, Centre de Recherche en Biomédecine de Strasbourg, Université de Strasbourg, Strasbourg, and Service de Pharmacie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Herrmann S, Giesel-Gerstmeier J, Steiner T, Lendholt F, Fenske D. Introduction of Unit-Dose Care in the 1,125 Bed Teaching Hospital: Practical Experience and Time Saving on Wards. J Multidiscip Healthc 2024; 17:1137-1145. [PMID: 38500480 PMCID: PMC10946279 DOI: 10.2147/jmdh.s450203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/28/2024] [Indexed: 03/20/2024] Open
Abstract
Purpose The shortage of nursing staff as well as the slow progress in the German health care system's digitalisation has gained much attention due to COVID-19. Patient-specific medication management using the unit-dose dispensing system (UDDS) has the potential for a lasting and positive influence on both digitalisation and the relief of nursing staff. Methods Nursing staff UDDS-acceptance was determined via a validated online survey. For the evaluation of stock keeping on the wards, the delivery quantities were determined for a comparative period before and after the introduction of the UDDS. The time required for on-ward medication-related processes on ward before and after the introduction of UDDS was recorded based on a survey form and the nursing relief in full-time equivalent (FTE) was calculated using the data obtained. Results We show that nurses appreciate the UDDS and confirm a significant reduction in drug stocks on the wards. The UDDS reduces the time needed to dispense medications from 4.52 ± 0.35 min to 1.67 ± 0.15 min/day/patient. In relation to the entire medication process, this corresponds to a reduction of 50% per day and per patient. Based on 40,000 patients/year and a supply of 1,125 beds with unit-dose blisters, 7.36 FTE nursing staff can be relieved per year. In contrast, 6.5 FTE in the hospital pharmacy are required for supplying the hospitals. Conclusion UDDS is well accepted by nurses, reduces stock levels on ward, and fulfils criteria as a nursing-relief measure.
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Affiliation(s)
- Saskia Herrmann
- Hospital Pharmacy, Helios Kliniken GmbH, Berlin, Berlin, Germany
- Department of Pharmaceutical/Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Thuringia, Germany
| | | | - Thomas Steiner
- Department of Urology, Helios Klinikum Erfurt, Erfurt, Thuringia, Germany
- Medicine, HMU Health and Medical University Erfurt, Erfurt, Thuringia, Germany
| | | | - Dominic Fenske
- Hospital Pharmacy, Helios Kliniken GmbH, Berlin, Berlin, Germany
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Burgos-Alonso N, Torrecilla M, Mendiguren A, Pérez-Gómez Moreta M, Bruzos-Cidón C. Strategies to Improve Therapeutic Adherence in Polymedicated Patients over 65 Years: A Systematic Review and Meta-Analysis. PHARMACY 2024; 12:35. [PMID: 38392942 PMCID: PMC10892390 DOI: 10.3390/pharmacy12010035] [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: 11/23/2023] [Revised: 01/02/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Part of the population over 65 years of age suffer from several pathologies and are therefore polymedicated. In this systematic review and metanalysis, we aimed to determine the efficacy of several strategies developed to improve adherence to pharmacological treatment in polymedicated elderly people. DESIGN Web Of Science, PubMed and the Cochrane Library were searched until 2 January 2024. In total, 17 of the 1508 articles found evaluated the efficacy of interventions to improve adherence to medication in polymedicated elderly patients. Methodological quality and the risk of bias were rated using the Cochrane risk of bias tool. Open Meta Analyst® software was used to create forest plots of the meta-analysis. RESULTS In 11 of the 17 studies, an improvement in adherence was observed through the use of different measurement tools and sometimes in combination. The most frequently used strategy was using instructions and counselling, always in combination, in a single strategy used to improve adherence; one involved the use of medication packs and the other patient follow-up. In both cases, the results in improving adherence were positive. Five studies using follow-up interventions via visits and phone calls showed improved adherence on the Morisky Green scale compared to those where usual care was received [OR = 1.900; 95% CI = 1.104-3.270] (p = 0.021). DISCUSSION There is a high degree of heterogeneity in the studies analyzed, both in the interventions used and in the measurement tools for improving adherence to treatment. Therefore, we cannot make conclusions about the most efficacious strategy to improve medication adherence in polymedicated elderly patients until more evidence of single-intervention strategies is available.
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Affiliation(s)
- Natalia Burgos-Alonso
- Public Health Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - María Torrecilla
- Pharmacology Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - Aitziber Mendiguren
- Pharmacology Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - Marta Pérez-Gómez Moreta
- Public Health Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
| | - Cristina Bruzos-Cidón
- Nursing I Department, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
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Onor IO, Ahmed F, Nguyen AN, Ezebuenyi MC, Obi CU, Schafer AK, Borghol A, Aguilar E, Okogbaa JI, Reisin E. Polypharmacy in chronic kidney disease: Health outcomes & pharmacy-based strategies to mitigate inappropriate polypharmacy. Am J Med Sci 2024; 367:4-13. [PMID: 37832917 DOI: 10.1016/j.amjms.2023.10.003] [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: 02/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023]
Abstract
The rising prevalence of comorbidities in an increasingly aging population has sparked a reciprocal rise in polypharmacy. Patients with chronic kidney disease (CKD) have a greater burden of polypharmacy due to the comorbidities and complications associated with their disease. Polypharmacy in CKD patients has been linked to myriad direct and indirect costs for patients and the society at large. Pharmacists are uniquely positioned within the healthcare team to streamline polypharmacy management in the setting of CKD. In this article, we review the landscape of polypharmacy and examine its impacts through the lens of the ECHO model of Economic, Clinical, and Humanistic Outcomes. We also present strategies for healthcare teams to improve polypharmacy care through comprehensive medication management process that includes medication reconciliation during transitions of care, medication therapy management, and deprescribing. These pharmacist-led interventions have the potential to mitigate adverse outcomes associated with polypharmacy in CKD.
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Affiliation(s)
- IfeanyiChukwu O Onor
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA; Department of Pharmacy, University Medical Center New Orleans, New Orleans, LA, USA.
| | - Fahamina Ahmed
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; East Jefferson General Hospital-Family Medicine Clinic, Metairie, LA, USA
| | - Anthony N Nguyen
- Department of Pharmacy, Ochsner Health System, Jefferson, LA, USA
| | - Michael C Ezebuenyi
- Department of Pharmacy, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Collins Uchechukwu Obi
- Medical Laboratory Science Department, Nnamdi Azikiwe University, Nnewi Campus, Anambra, Nigeria
| | - Alison K Schafer
- Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Amne Borghol
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA; Department of Pharmacy, University Medical Center New Orleans, New Orleans, LA, USA
| | - Erwin Aguilar
- Department of Medicine, Section of Nephrology and Hypertension, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - John I Okogbaa
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Efrain Reisin
- Department of Medicine, Section of Nephrology and Hypertension, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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Nguyen M, Beier MT, Louden DN, Spears D, Gray SL. The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials. Sr Care Pharm 2023; 38:506-523. [PMID: 38041222 DOI: 10.4140/tcp.n.2023.506] [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: 12/03/2023]
Abstract
Background Polypharmacy is common among older people and may be associated with adverse drug events (ADEs) and poor health outcomes. Pharmacists are well-positioned to reduce polypharmacy and potentially inappropriate medications. Objective The objective of this narrative review was to summarize the results from randomized-controlled trials that evaluated pharmacist-led interventions with the goal or effect to deprescribe medications in older individuals. Data Sources We searched Medline, Embase, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. Data Synthesis Of the 25 studies included, the interventions were conducted in nursing facilities (n = 8), outpatient/community dwellings (n = 8), or community pharmacies (n = 9). Interventions were categorized as comprehensive medication reviews (n = 10), comprehensive medication reviews with pharmacist follow-up (n = 11), and educational interventions provided to patients and/or providers (n = 4). Pharmacist-led interventions had a beneficial effect on 22 out of 32 total medication-related outcomes (eg, number of medications, potentially inappropriate medications, or discontinuation). Most (n = 18) studies reported no evidence of an effect for other outcomes such as health care use, mortality, patient-centered outcomes (falls, cognition, function, quality of life), and ADEs. Discussion Interventions led to improvement in 69% of the medication-related outcomes examined across study settings. Five studies measured ADEs with none accounting for adverse drug-withdrawal events. Large well-designed studies that are powered to find an effect on patient-centered outcomes are needed. Conclusion Pharmacist-led interventions had a significant beneficial effect on medication-related outcomes. There was little evidence of benefit on other outcomes.
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Affiliation(s)
- Michelle Nguyen
- 1University of Washington School of Pharmacy, Seattle, Washington
| | - Manju T Beier
- 2University of Michigan, Senior Partner Geriatric Consultant Resources LLC, Ann Arbor, Michigan
| | - Diana N Louden
- 3University of Washington Libraries, Seattle, Washington
| | - Darla Spears
- 4Clinical Consultant Pharmacist, Edmond, Oklahoma
| | - Shelly L Gray
- 1University of Washington School of Pharmacy, Seattle, Washington
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Zhou D, Chen Z, Tian F. Deprescribing Interventions for Older Patients: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2023; 24:1718-1725. [PMID: 37582482 DOI: 10.1016/j.jamda.2023.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVES Deprescribing reduces polypharmacy in older adults. A thorough study of the effect of deprescribing interventions on clinical outcomes in older adults is presently lacking. As a result, we evaluated the impact of deprescribing on clinical outcomes in older patients. DESIGN Meta-analysis and systematic review of randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane Library were searched from the time of creation to March 2023. SETTING AND PARTICIPANTS Randomized controlled trial with participants at least 60 years old. MEASURES Mortality, falls (number of fallers), hospitalization rates, emergency department visits, medication adherence, HRQoL (health-regulated quality of life), incidence of ADR (adverse drug reactions), PIM (potentially inappropriate medication), and PPO (potentially prescription omission) were evaluated in the meta-analysis. RESULTS A total of 32 RCTs (18,670 patients) were included. Deprescribing interventions significantly reduced proportions of older adults with PIM, PPO, and the incidence of ADRs. The interventions group also improved medication compliance. CONCLUSIONS AND IMPLICATIONS Compared to routine care, deprescribing interventions significantly improve clinical outcome indicators for older adults.
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Affiliation(s)
- Dan Zhou
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China; Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
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11
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Gray SL, Perera S, Soverns T, Hanlon JT. Systematic Review and Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults: An Update. Drugs Aging 2023; 40:965-979. [PMID: 37702981 PMCID: PMC10600043 DOI: 10.1007/s40266-023-01064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND We previously reported that interventions to optimize medication use reduced adverse drug reactions (ADRs) by 21% and serious ADRs by 36% in older adults. With new evidence, we sought to update the systematic review and meta-analysis. METHOD We searched OVID, Cochrane Library, ClinicalTrials.gov and Google Scholar from 30 April 2017-30 April 2023. Included studies had to be randomized controlled trials of older adults (mean age ≥65 years) taking medications that examined the outcome of ADRs. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. The outcomes were any and serious ADRs. We performed subgroup analyses by intervention type and setting. Random-effects models were used to combine the results from multiple studies and create summary estimates. RESULTS Six studies are new to the update, resulting in 19 total studies (15,675 participants). Interventions were pharmacist-led (10 studies), other healthcare professional-led (5 studies), technology based (3 studies), and educational (1 study). The interventions were implemented in various clinical settings, including hospitals, outpatient clinics, long-term care facilities/rehabilitation wards, and community pharmacies. In the pooled analysis, the intervention group participants were 19% less likely to experience an ADR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68-0.96) and 32% less likely to experience a serious ADR (OR 0.68, 95% CI 0.48-0.96). We also found that pharmacist-led interventions reduced the risk of any ADR by 35%, compared with 8% for other types of interventions. CONCLUSION Interventions significantly and substantially reduced the risk of ADRs and serious ADRs in older adults. Future research should examine whether effectiveness of interventions vary across health care settings to identify those most likely to benefit. Implementation of successful interventions in health care systems may improve medication safety in older patients.
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Affiliation(s)
- Shelly L Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA.
| | - Subashan Perera
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tim Soverns
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA
| | - Joseph T Hanlon
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [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: 10/13/2023]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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13
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Nishida S, Kato T, Hayashi Y, Yamada S, Fujii H, Yamada M, Asai N, Shimizu S, Niwa T, Iihara H, Kubota S, Sakai M, Takahashi Y, Takao K, Mizuno M, Hirota T, Kobayashi R, Horikawa Y, Yabe D, Suzuki A. Effectiveness of countermeasure for polypharmacy by multidisciplinary team review in patients with diabetes mellitus. J Diabetes Investig 2023; 14:1202-1208. [PMID: 37357565 PMCID: PMC10512905 DOI: 10.1111/jdi.14046] [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: 02/20/2023] [Revised: 05/22/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023] Open
Abstract
AIMS/INTRODUCTION Polypharmacy in diabetes patients is related to worse clinical outcomes. The aim of this study was to evaluate the usefulness of our countermeasure for polypharmacy, which combines a pharmacist check followed by a multidisciplinary team review in diabetic patients with polypharmacy. METHODS A single-center, retrospective observational study was conducted at Gifu University Hospital. Study participants included diabetic patients taking six or more drugs on admission to the diabetes ward between July 2021 and June 2022. Drugs which were discontinued by the present countermeasure were examined, and the number of drugs being taken by each patient was compared between admission and discharge. RESULTS 102 of 308 patients were taking six or more drugs on admission. The drugs being taken by these patients were evaluated by pharmacists using a checklist for polypharmacy. Eighty-four drugs which were evaluated as inappropriate or potentially inappropriate medications by pharmacists were discontinued following the multidisciplinary team review. The median and mean number of drugs taken by the 102 patients significantly decreased from 9.0 (IQR: 8-12) and 9.26 ± 2.64 on admission to 9.0 (IQR: 6-10) and 8.42 ± 2.95 on discharge (P = 0.0002). We followed up with these patients after discontinuation of the drugs and confirmed that their clinical status had not deteriorated. CONCLUSION The present countermeasure for polypharmacy, which combines a pharmacist check based on a checklist for evaluating polypharmacy followed by a multidisciplinary team review, was useful for reducing the number of inappropriate or potentially inappropriate medications taken by diabetes patients with polypharmacy.
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Affiliation(s)
| | - Takehiro Kato
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Yuichi Hayashi
- Faculty of Nursing ScienceTsuruga Nursing UniversityTsurugaJapan
| | - Shoya Yamada
- Department of PharmacyGifu University HospitalGifuJapan
| | | | - Michi Yamada
- Department of PharmacyGifu University HospitalGifuJapan
| | - Nao Asai
- Department of PharmacyGifu University HospitalGifuJapan
| | | | - Takashi Niwa
- Department of PharmacyGifu University HospitalGifuJapan
| | - Hirotoshi Iihara
- Department of PharmacyGifu University HospitalGifuJapan
- Patient Safety DivisionGifu University HospitalGifuJapan
| | - Sodai Kubota
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Mayu Sakai
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Yoshihiro Takahashi
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Ken Takao
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Masami Mizuno
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Takuo Hirota
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
| | - Ryo Kobayashi
- Department of PharmacyGifu University HospitalGifuJapan
- Laboratory of Advanced Medical PharmacyGifu Pharmaceutical UniversityGifuJapan
| | - Yukio Horikawa
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
- Center for Patient Flow ManagementGifu University HospitalGifuJapan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and MetabolismGifu University Graduate School of MedicineGifuJapan
- Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan
- Center for One Medicine Innovative Translational ResearchGifu University Institute for Advanced StudyGifuJapan
- Preemptive Food Research CenterGifu University Institute for Advanced StudyGifuJapan
- Center for Research, Education and Lifestyle DesignGifu UniversityGifuJapan
| | - Akio Suzuki
- Department of PharmacyGifu University HospitalGifuJapan
- Laboratory of Advanced Medical PharmacyGifu Pharmaceutical UniversityGifuJapan
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14
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Chan M, Plakogiannis R, Stefanidis A, Chen M, Saraon T. Pharmacist-Led Deprescribing for Patients With Polypharmacy and Chronic Disease States: A Retrospective Cohort Study. J Pharm Pract 2023; 36:1192-1200. [PMID: 35522029 DOI: 10.1177/08971900221097246] [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: 11/17/2022]
Abstract
Background: Current literature and practice have demonstrated that pharmacists have an integral role in deprescribing. However, research regarding their impact on patients with chronic diseases is limited. Objective: To assess the impact of a pharmacist-led intervention on deprescribing inappropriate medication for patients with chronic diseases within a four-month study period compared to patients receiving usual care. Methods: This study was conducted at NYU Langone Health. Patients of the intervention group were referred by a provider and met the criteria of polypharmacy, required chronic disease states management, were nonadherent to medications, had poor health literacy, or required titration for heart failure (HF) guideline directed medical therapy. Results: A total of 142 patients were reviewed over a two-year period. At the end of the study period, the median number of medications for the two respective groups was similar (11 [4 - 30] vs 11 [2 - 23]). The pharmacist-led intervention had on average one medication deprescribed (m = -1.00, sd = 2.57), whereas the control group had on average .44 additional medications (m = 0.44, sd = 3.32) prescribed. Furthermore, the intervention group presented statistically significant differences (P = 0.046) regarding their diastolic blood pressure after the pharmacists' intervention (m = 72.69, sd = 11.64). Most importantly, patients with HF presented statistically significant improvement in their ejection fractions after the intervention (m = 41.46%, sd = 19.28%). Conclusion: The pharmacist-led intervention resulted in significant discontinuation of medications for patients in the intervention group compared to those in the usual care group within four-months.
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Affiliation(s)
- Mabel Chan
- Ambulatory Care Clinical Pharmacist, NYC Health+Hospitals, Brooklyn, NY, USA
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
| | - Roda Plakogiannis
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
- PGY-2 Ambulatory Care Residency Program Director, NYU Langone Health, New York, NY, USA
| | - Abraham Stefanidis
- Department of Management, The Peter J. Tobin College of Business, St. John's University, New York, NY, USA
| | - Mandy Chen
- Arnold and Marie Schwartz College of Pharmacy & Health Sciences Long Island University, Brooklyn, NY, USA
- Shields Health Solutions, Stoughton, Massachusetts, UK
| | - Tajinderpal Saraon
- Physician, Department of Medicine, NYU Grossman School of Medicine, NY, USA
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15
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Walker LE, Pirmohamed M. Increasing trend in hospitalisation due to adverse drug reactions: can we stem the tide? Drug Ther Bull 2023:dtb.2022.000050. [PMID: 37193588 DOI: 10.1136/dtb.2022.000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Living with multiple long-term health conditions (multimorbidity) is increasingly common in older age. The more long-term conditions that an individual has, the more medicines they are likely to take. Hospitalisation as a consequence of medication-related harm is increasing and a concerted effort is needed to reduce the burden of harm caused by medication. However, making decisions about the balance between benefit and harm for an older person with multimorbidity and polypharmacy is very complex. There are various clinical tools that can help to identify patients at higher risk of harm and numerous strategies, including medicines optimisation reviews that incorporate personalised health information, to try to reduce risk. Further education and training of the healthcare professionals is needed to equip the multidisciplinary workforce with the skills and knowledge to address these challenges. This article discusses some of the changes that can be implemented now and highlights areas that will require more research before they can be introduced, in order to help patients to get the best out of their medicines.
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Affiliation(s)
- Lauren E Walker
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
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Lee S, Yu YM, Han E, Park MS, Lee JH, Chang MJ. Effect of Pharmacist-Led Intervention in Elderly Patients through a Comprehensive Medication Reconciliation: A Randomized Clinical Trial. Yonsei Med J 2023; 64:336-343. [PMID: 37114637 PMCID: PMC10151230 DOI: 10.3349/ymj.2022.0620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE Polypharmacy can cause drug-related problems, such as potentially inappropriate medication (PIM) use and medication regimen complexity in the elderly. This study aimed to investigate the feasibility and effectiveness of a collaborative medication review and comprehensive medication reconciliation intervention by a pharmacist and hospitalist for older patients. MATERIALS AND METHODS This comprehensive medication reconciliation study was designed as a prospective, open-label, randomized clinical trial with patients aged 65 years or older from July to December 2020. Comprehensive medication reconciliation comprised medication reviews based on the PIM criteria. The discharge of medication was simplified to reduce regimen complexity. The primary outcome was the difference in adverse drug events (ADEs) throughout hospitalization and 30 days after discharge. Changes in regimen complexity were evaluated using the Korean version of the medication regimen complexity index (MRCI-K). RESULTS Of the 32 patients, 34.4% (n=11/32) reported ADEs before discharge, and 19.2% (n=5/26) ADEs were reported at the 30-day phone call. No ADEs were reported in the intervention group, whereas five events were reported in the control group (p=0.039) on the 30-day phone call. The mean acceptance rate of medication reconciliation was 83%. The mean decreases of MRCI-K between at the admission and the discharge were 6.2 vs. 2.4, although it was not significant (p=0.159). CONCLUSION As a result, we identified the effect of pharmacist-led interventions using comprehensive medication reconciliation, including the criteria of the PIMs and the MRCI-K, and the differences in ADEs between the intervention and control groups at the 30-day follow-up after discharge in elderly patients. TRIAL REGISTRATION (Clinical trial number: KCT0005994).
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Affiliation(s)
- Sunmin Lee
- Department of Pharmaceutical Medicines and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea
- Department of Pharmacy, Inha University Hospital, Incheon, Korea
| | - Yun Mi Yu
- Department of Pharmaceutical Medicines and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea
| | - Euna Han
- Department of Pharmaceutical Medicines and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea
| | - Min Soo Park
- Department of Pharmaceutical Medicines and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Korea
- Department of Clinical Pharmacology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Hwan Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.
| | - Min Jung Chang
- Department of Pharmaceutical Medicines and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea.
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Fashami FM, Nili M, Mottaghi M, Farahani AV. Measuring Empathy in Iranian Pharmacy Students Using the Jefferson Scale of Empathy-Health Profession Student Version. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:ajpe8687. [PMID: 35470168 PMCID: PMC10159512 DOI: 10.5688/ajpe8687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/07/2022] [Indexed: 05/06/2023]
Abstract
Objective. To assess validity of the Farsi-translated version of the Jefferson Scale of Empathy-Health Profession Student version (JSE-HPS) and measure empathy scores of Iranian pharmacy students.Methods. The JSE-HPS questionnaire was administered to 504 Iranian pharmacy students in 2019. Confirmatory factor analysis and exploratory factor analysis were used to explore the underlying components and construct validity. Group comparisons of the empathy scores and the underlying components were conducted using statistical tests.Results. Based on 496 useable survey questionnaires, three domains of empathy among Iranian pharmacy students were confirmed by confirmatory factor analysis: compassionate care, perspective taking, and standing in a patient's shoes. Two items in the JSE-HPS were removed, as their factor loadings were under the permissible limits in exploratory factor analysis. Empathy scores were significantly higher among female pharmacy students.Conclusion. These findings support the validity and reliability of the Farsi version of the JSE-HPS among Iranian pharmacy students.
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Affiliation(s)
- Fatemeh Mirzayeh Fashami
- McMaster University, Department of Health Research Methods Evidence and Impact, Hamilton, ON, Canada
| | - Mona Nili
- West Virginia University, School of Pharmacy, Morgantown, West Virginia
| | | | - Ali Vasheghani Farahani
- Tehran University of Medical Science, Pharmaceutical Management and Economics Research Center, Tehran, Iran
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Pharmacists' clinical roles and activities in inpatient hospice and palliative care: a scoping review. Int J Clin Pharm 2023:10.1007/s11096-023-01535-7. [PMID: 36773207 PMCID: PMC9918816 DOI: 10.1007/s11096-023-01535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/03/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Pharmacists contribute to medication safety by providing their services in various settings. However, standardized definitions of the role of pharmacists in hospice and palliative care (HPC) are lacking. AIM The purpose of this scoping review was to provide an overview of the evidence on the role of pharmacists and to map clinical activities in inpatient HPC. METHOD We performed a scoping review according to the PRISMA-ScR extension in CINAHL, Embase, and PubMed. We used the American Society of Hospital Pharmacists (ASHP) Guidelines on the Pharmacist's Role in Palliative and Hospice Care as a framework for standardized categorization of the identified roles and clinical activities. RESULTS After screening 635 records (published after January 1st, 2000), the scoping review yielded 23 publications reporting various pharmacy services in HPC. The articles addressed the five main categories in the following descending order: 'Medication order review and reconciliation', 'Medication counseling, education and training', 'Administrative Roles', 'Direct patient care', and 'Education and scholarship'. A total of 172 entries were mapped to the subcategories that were added to the main categories. CONCLUSION This scoping review identified a variety of pharmacists' roles and clinical activities. The gathered evidence will help to establish and define the role of pharmacists in inpatient hospice and palliative care.
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Croke A, Cardwell K, Clyne B, Moriarty F, McCullagh L, Smith SM. The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy: a systematic review. BMC PRIMARY CARE 2023; 24:41. [PMID: 36747132 PMCID: PMC9901090 DOI: 10.1186/s12875-022-01952-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 12/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Polypharmacy and associated potentially inappropriate prescribing (PIP) place a considerable burden on patients and represent a challenge for general practitioners (GPs). Integration of pharmacists within general practice (herein 'pharmacist integration') may improve medications management and patient outcomes. This systematic review assessed the effectiveness and costs of pharmacist integration. METHODS A systematic search of ten databases from inception to January 2021 was conducted. Studies that evaluated the effectiveness or cost of pharmacist integration were included. Eligible interventions were those that targeted medications optimization compared to usual GP care without pharmacist integration (herein 'usual care'). Primary outcomes were PIP (as measured by PIP screening tools) and number of prescribed medications. Secondary outcomes included health-related quality of life, health service utilization, clinical outcomes, and costs. Randomised controlled trials (RCTs), non-RCTs, interrupted-time-series, controlled before-after trials and health-economic studies were included. Screening and risk of bias using Cochrane EPOC criteria were conducted by two reviewers independently. A narrative synthesis and meta-analysis of outcomes where possible, were conducted; the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS In total, 23 studies (28 full text articles) met the inclusion criteria. In ten of 11 studies, pharmacist integration probably reduced PIP in comparison to usual care (moderate certainty evidence). A meta-analysis of number of medications in seven studies reported a mean difference of -0.80 [-1.17, -0.43], which indicated pharmacist integration probably reduced number of medicines (moderate certainty evidence). It was uncertain whether pharmacist integration improved health-related quality of life because the certainty of evidence was very low. Twelve health-economic studies were included; three investigated cost effectiveness. The outcome measured differed across studies limiting comparisons and making it difficult to make conclusions on cost effectiveness. CONCLUSIONS Pharmacist integration probably reduced PIP and number of medications however, there was no clear effect on other patient outcomes; and while interventions in a small number of studies appeared to be cost-effective, further robust, well-designed cluster RCTs with economic evaluations are required to determine cost-effectiveness of pharmacist integration. TRIAL REGISTRATION CRD42019139679.
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Affiliation(s)
- Aisling Croke
- grid.4912.e0000 0004 0488 7120Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Karen Cardwell
- Health Information and Quality Authority, Dublin, Ireland
| | - Barbara Clyne
- grid.4912.e0000 0004 0488 7120Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- grid.4912.e0000 0004 0488 7120School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Laura McCullagh
- grid.416409.e0000 0004 0617 8280National Centre for Pharmacoeconomics, St James’s Hospital, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - Susan M. Smith
- grid.4912.e0000 0004 0488 7120Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705Discipline of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
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Wernli U, Dürr F, Jean-Petit-Matile S, Kobleder A, Meyer-Massetti C. Subcutaneous Drugs and Off-label Use in Hospice and Palliative Care: A Scoping Review. J Pain Symptom Manage 2022; 64:e250-e259. [PMID: 35870656 DOI: 10.1016/j.jpainsymman.2022.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Subcutaneous drug administration is an interesting approach for symptom control in hospice and palliative care. However, most drugs have no marketing authorization for subcutaneous administration and are therefore used off-label. In order to meet the requirements of a safe and effective drug therapy, especially in highly vulnerable patients, it is essential to investigate the scope of evidence of these common practices. OBJECTIVES The purpose of this scoping review was to provide an overview of available data on the tolerability and/or effectiveness of subcutaneously administered and off-label used drugs. METHOD We performed a scoping review according to the PRISMA extension to identify data available on the tolerability and/or effectiveness of 17 predefined drugs that are commonly administered subcutaneously in Swiss hospices and hospice-like institutions and that have no marketing authorization (off-label use). RESULTS The scoping review identified 57 studies with most data available on their tolerability (68% local, 54% systemic), clinical effects (82%), details on dosage (96%) and routes of application (100%). Information on pharmacokinetic properties was mostly missing and only available for fentanyl, levetiracetam, midazolam, and ondansetron. For seven drugs, less than five articles were identified and no studies on codeine or clonazepam were available. CONCLUSION This work provides an overview of current evidence on subcutaneous and off-label used drugs in hospice and palliative care. Although both are common practices, evidence on tolerability and effectiveness, particularly pharmacokinetic data, is limited and the identified information gaps need to be closed. This work establishes a basis for further research in this area.
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Affiliation(s)
- Ursina Wernli
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Graduate School for Health Sciences (U.W.), University of Bern, Switzerland.
| | - Fabienne Dürr
- Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
| | | | - Andrea Kobleder
- Institute of Applied Nursing Science (A.K.), Eastern Switzerland University of Applied Sciences OST, St Gallen, Switzerland
| | - Carla Meyer-Massetti
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
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Tang H, Gao L, Li Y. Influence of the Clinical Nursing Pathway on Nursing Outcomes and Complications of Cervical Carcinoma Patients Undergoing Chemotherapy via PICC. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:4040033. [PMID: 36212962 PMCID: PMC9546696 DOI: 10.1155/2022/4040033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
Background Cervical Carcinoma (CC) is the second most common cause of death in women, with most patients being diagnosed at an advanced stage. The conventional treatment for CC, with a long chemotherapy treatment cycle, is less than satisfactory and will cause serious damage to the patient's blood vessels. Objective To analyze the impact of the clinical nursing pathway (CNP) on the incidence of complications and adverse prognosis in patients undergoing chemotherapy for CC via peripherally inserted central catheters (PICC). Materials and Methods This study enrolled 157 CC patients who underwent PICC chemotherapy in the Shaanxi Provincial Cancer Hospital between March 2017 and April 2020 and assigned them between the two groups according to different nursing interventions. Ninety-three patients treated with CNP intervention were included in the research group (RG), and sixty-four cases treated with the routine nursing intervention were included in the control group (CG). The self-care ability and intervention satisfaction of patients were assessed using the self-care ability scale and the intervention satisfaction questionnaire, respectively, both developed by our hospital. The complication rate was observed in both cohorts, and the adverse prognosis of patients was statistically analyzed. Finally, an assessment was made on the patients' quality of life (QOL) using the quality of life questionnaire core 30 (QLQ-C30). Results Higher scores of self-management information, catheter nursing ability, self-care compliance, and abnormal situation management were determined in RG after the nursing intervention. RG also outperformed CG in the overall incidence rates of complications and poor prognosis. Moreover, RG presented statistically higher nursing satisfaction and QLQ-C30 scores than CG after the nursing intervention. Conclusion CNP has a significant nursing effect on patients with CC treated with PICC chemotherapy, which can not only reduce the incidence of postchemotherapy complications but also improve patient prognosis, satisfaction, and life quality, with the value for clinical promotion.
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Affiliation(s)
- Hongxia Tang
- Medical Oncology, Shaanxi Provincial Cancer Hospital, Xi'an 710061, Shaanxi, China
| | - Li Gao
- Medical Oncology, Shaanxi Provincial Cancer Hospital, Xi'an 710061, Shaanxi, China
| | - Yahui Li
- Department of Gynecology and Oncology, Shaanxi Cancer Hospital, Xi'an 710061, Shaanxi, China
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DAL Ş, UÇAR N, ALTIPARMAK Ö, SANCAR M, OKUYAN B. Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2022. [DOI: 10.33808/clinexphealthsci.1012114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index.
Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®.
Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9).
Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in older adults.
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Stakeholders’ Views about the Management of Stable Chronic Conditions in Community Pharmacies. PHARMACY 2022; 10:pharmacy10030059. [PMID: 35736774 PMCID: PMC9231151 DOI: 10.3390/pharmacy10030059] [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: 05/17/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 11/21/2022] Open
Abstract
The role of the community pharmacist has evolved to include the provision of more clinical services for patients. Those people who have stable chronic conditions will be managed in community pharmacies. This qualitative study used semi-structured in-depth interviews to understand the potential of providing additional patient-centred care for patients with stable chronic conditions in community pharmacies and identify potential limitations of this approach. Participants were recruited from Welsh Government, Local Health Boards (LHBS), Community Pharmacy Wales (CPW) and the Royal Pharmaceutical Society Wales (RPSW). The interviews were audio-recorded, transcribed verbatim, and analysed thematically. Eight interviews were conducted. The identified themes were as follows: (1) inconsistency and bureaucracy in commissioning pharmacy services; (2) availability of funding and resources; (3) disagreement and uncertainty about the contribution of the community pharmacy sector; (4) continuity of patient medical information and fragmented care; (5) accessibility, capacity and facilities in community pharmacy; (6) pharmacy education and clinical expertise, and (7) patient acceptability. It was clear that the potential benefit of managing stable chronic diseases in community pharmacies was recognised; however, several limitations expressed by stakeholders of pharmacy services need to be considered prior to moving forward.
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How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention. J Pers Med 2022; 12:jpm12050752. [PMID: 35629175 PMCID: PMC9144280 DOI: 10.3390/jpm12050752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.
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Pharmacist Intention to Provide Medication Therapy Management Services in Saudi Arabia: A Study Using the Theory of Planned Behaviour. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095279. [PMID: 35564673 PMCID: PMC9101803 DOI: 10.3390/ijerph19095279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 12/10/2022]
Abstract
Medication therapy management (MTM) is provided by pharmacists and other healthcare providers, improves patient health status, and increases the collaboration of MTM providers with others. However, little is known about pharmacists’ intention to provide MTM services in Saudi Arabia. This study aimed to predict the pharmacists’ willingness in this nation to commit to providing MTM services there. This study used a cross-sectional questionnaire based on the theory of planned behaviour (TPB). The survey was distributed to 149 pharmacists working in hospital and community pharmacies. It included items measuring pharmacist attitudes, intentions, subjective norms, perceived behavioural control, knowledge about the provision of MTM services, and other sociodemographic and pharmacy practice-related items. The pharmacists had a positive attitude towards MTM services (mean = 6.15 ± 1.12) and strong intention (mean = 6.09 ± 1.15), highly perceived social pressure to provide those services (mean = 5.42 ± 1.03), strongly perceived control over providing those services (mean = 4.98 ± 1.05), and had good MTM knowledge (mean = 5.03 ± 1.00). Pharmacists who completed a pharmacy residency programme and had good knowledge of MTM services and a positive attitude towards them usually strongly intended to provide MTM services. Thus, encouraging pharmacists to complete pharmacy residency programmes and educating them about the importance and provision of MTM services will enhance their motivation to provide them.
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Foster AA, Lindenau R, Clark CM, Wahler RG. Targeted Medication Review of Falls-Risk Medications in Older Patients: A Community Pharmacy-Based Approach. Sr Care Pharm 2022; 37:104-113. [PMID: 35197153 DOI: 10.4140/tcp.n.2022.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To assess a community pharmacist-provided targeted medication review (TMR) intervention to reduce the number of falls risk-increasing drugs (FRIDs) prescribed to older patients in a community pharmacy setting. Design A single-site, prospective, interventional pilot study with a historical control group. Setting A single independent community pharmacy in rural Western New York. Participants A convenience sample of subjects was recruited for the intervention group based on the following inclusion criteria: 65 years of age or older, at least one prescription filled at the pharmacy within the past 90 days from date of enrollment in study, enrolled in a local Medicare plan, and prescription for at least one prespecified FRID filled at the pharmacy within 90 days before date of enrollment in study. A control group was collected that had different Medicare Part D plans than the intervention group but otherwise met inclusion criteria and ensured that between all of the control-group patients we included at least one patient prescribed each of the FRID classes that were found in the intervention group. Thirty-six subjects completed the study intervention, and 63 controls were collected. This offset in numbers between groups resulted from intervention subjects taking multiple FRIDs and the control needing to take the same class of FRID, thus one intervention subject may have required multiple control subjects to parallel each FRID class. Intervention The intervention involved the community pharmacist assessing the patient's fall risk, then educating the patient on the risks of the FRID he or she was prescribed, and recommending to either replace or discontinue the FRID. The outcomes assessment occurred three months later, with the pharmacist repeating the falls-risk assessment and following up regarding the patient's agreed-upon action plan. Results The intervention group had 52 FRIDs identified while the control group had 89. The discontinuation rate of FRIDs at three months was significantly higher in the intervention group (7.7% versus 0%; P = 0.0172). Conclusion This study demonstrated that a community pharmacist TMR intervention can reduce the use of FRIDs.
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Affiliation(s)
| | - Ryan Lindenau
- 1Middleport Family Health Center, Middleport, New York
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Romano S, Figueira D, Teixeira I, Perelman J. Deprescribing Interventions among Community-Dwelling Older Adults: A Systematic Review of Economic Evaluations. PHARMACOECONOMICS 2022; 40:269-295. [PMID: 34913143 DOI: 10.1007/s40273-021-01120-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Deprescribing can reduce the use of inappropriate or unnecessary medication; however, the economic value of such interventions is uncertain. OBJECTIVE This study seeks to identify and synthetise the economic evidence of deprescribing interventions among community-dwelling older adults. METHODS Full economic evaluation studies of deprescribing interventions, conducted in the community or primary care settings, in community-dwelling adults aged ≥ 65 years were systematically reviewed. MEDLINE, EconLit, Scopus, Web of Science, CEA-TUFTS, CRD York and Google Scholar databases were searched from inception to February 2021. Two researchers independently screened all retrieved articles according to inclusion and exclusion criteria. The main outcome was the economic impact of the intervention from any perspective, converted into 2019 US Dollars. The World Health Organization threshold of 1 gross domestic product per capita was used to define cost effectiveness. Studies were appraised for methodological quality using the extended Consensus on Health Economics Criteria checklist. RESULTS Of 6154 articles identified by the search strategy, 14 papers assessing 13 different interventions were included. Most deprescribing interventions included some type of medication review with or without a supportive educational component (n = 11, 85%), and in general were delivered within a pharmacist-physician care collaboration. Settings included community pharmacies, primary care/outpatient clinics and patients' homes. All economic evaluations were conducted within a time horizon varying from 2 to 12 months with outcomes in most of the studies derived from a single clinical trial. Main health outcomes were reported in terms of quality-adjusted life-years, prevented number of falls and the medication appropriateness index. Cost effectiveness ranged from dominant to an incremental cost-effectiveness ratio of $112,932 per quality-adjusted life-year, a value above the country's World Health Organization threshold. Overall, 85% of the interventions were cost saving, dominated usual care or were cost effective considering 1 gross domestic product per capita. Nine studies scored > 80% (good) and two scored ≤ 50% (low) on critical quality appraisal. CONCLUSIONS There is a growing interest in economic evaluations of deprescribing interventions focused on community-dwelling older adults. Although results varied across setting, time horizon and intervention, most were cost effective according to the World Health Organization threshold. Deprescribing interventions are promising from an economic viewpoint, but more studies are needed.
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Affiliation(s)
- Sónia Romano
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal.
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Débora Figueira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Inês Teixeira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Julian Perelman
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Lisbon, Portugal
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Costa JPD, Alves GADC, Guedes ÉDC, Fonseca FPDB, Souto RÁDDM, Lopes PQ, Golzio AMFDO. Analysis of potential drug interactions in medical clinic sector in a Hospital of João Pessoa - PB. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e18943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Farhat A, Abou-Karroum R, Panchaud A, Csajka C, Al-Hajje A. Impact of Pharmaceutical Interventions in Hospitalized Patients: A Comparative Study Between Clinical Pharmacists and an Explicit Criteria-Based Tool. Curr Ther Res Clin Exp 2021; 95:100650. [PMID: 34824649 PMCID: PMC8604771 DOI: 10.1016/j.curtheres.2021.100650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background It has been well recognized that pharmaceutical interventions (PIs) can prevent patient harm related to prescribing errors. Various tools have been developed to facilitate the detection and the reduction of inappropriate prescriptions and some have shown benefit on clinical outcomes. Objective The objective of this study was to evaluate the clinical, economical, and organizational impact of interventions generated by clinical pharmacists in hospitalized patients, and to evaluate the performance of an explicit tool, the Potentially Inappropriate Medication Checklist for Patients in Internal Medicine (PIM-Check), in detecting each pharmacist's intervention. Methods A cohort retrospective study was conducted on hospitalized patients. The impact of PIs based on pharmacists’ standard examination was evaluated using the Clinical, Economic, and Organizational (CLEO) tool. The performance of PIM-Check in detecting each intervention was assessed by conducting a retrospective medication review based on available information collected from patients’ records. A qualitative analysis was also conducted to identify the types of PIs that PIM-Check failed to detect. Results The study was performed on 162 patients with a median age of 68 years (interquartile range = 46–77 years) and a median hospital stay of 5 days (interquartile range = 4–7 days). The pharmacists generated 1.9 PIs per patient (n = 304) of which 31% were detected by PIM-Check. The acceptance rate of the interventions by physicians was 84% (n = 255). Among the accepted interventions, 53% (n = 136) had a clinical impact graded CL ≥ 2C (moderate or major), whereas the majority of them were not detected by PIM-Check (63%; 86 out of 136). In addition, 46% of accepted interventions (n = 117) were associated with a cost decrease, among which 62% were not detected by PIM-Check (73 out of 117). The qualitative analysis shows that PIM-Check mostly failed to detect PIs related to dose adjustment, overprescribing, and therapy monitoring. Conclusions According to the CLEO tool evaluation of PIs, our results show that clinical pharmacists’ interventions are associated with improved clinical outcomes. In comparison with pharmacists’ interventions, PIM-Check failed in detecting the majority of interventions associated with a moderate or major impact.
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Affiliation(s)
- Akram Farhat
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Rime Abou-Karroum
- Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.,Department of Pharmacy, Clemenceau Medical Center, Beirut, Lebanon
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Amal Al-Hajje
- Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
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Customisable Tablet Printing: The Development of Multimaterial Hot Melt Inkjet 3D Printing to Produce Complex and Personalised Dosage Forms. Pharmaceutics 2021; 13:pharmaceutics13101679. [PMID: 34683972 PMCID: PMC8538252 DOI: 10.3390/pharmaceutics13101679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
One of the most striking characteristics of 3D printing is its capability to produce multi-material objects with complex geometry. In pharmaceutics this translates to the possibility of dosage forms with multi-drug loading, tailored dosing and release. We have developed a novel dual material hot-melt inkjet 3D printing system which allows for precisely controlled multi-material solvent free inkjet printing. This reduces the need for time-consuming exchanges of printable inks and expensive post processing steps. With this printer, we show the potential for design of printed dosage forms for tailored drug release, including single and multi-material complex 3D patterns with defined localised drug loading where a drug-free ink is used as a release-retarding barrier. For this, we used Compritol HD5 ATO (matrix material) and Fenofibrate (model drug) to prepare both drug-free and drug-loaded inks with drug concentrations varying between 5% and 30% (w/w). The printed constructs demonstrated the required physical properties and displayed immediate, extended, delayed and pulsatile drug release depending on drug localisation inside of the printed formulations. For the first time, this paper demonstrates that a commonly used pharmaceutical lipid, Compritol HD5 ATO, can be printed via hot-melt inkjet printing as single ink material, or in combination with a drug, without the need for additional solvents. Concurrently, this paper demonstrates the capabilities of dual material hot-melt inkjet 3D printing system to produce multi-material personalised solid dosage forms.
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Leake Date HA, Alford K, Hounsome N, Moore D, Ing K, Vera JH. Structured medicines reviews in HIV outpatients: a feasibility study (The MOR Study). HIV Med 2021; 23:39-47. [PMID: 34469628 DOI: 10.1111/hiv.13158] [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: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Polypharmacy in people living with HIV (PLWH) increases the risks of medicine-related problems (events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes). We aimed to examine the feasibility and acceptability of a Medicines Management Optimisation Review (MOR) toolkit in HIV outpatients. METHODS This was a multi-centre randomized controlled study across four HIV centres. In all, 200 PLWH on combination antiretroviral therapy, either > 50 years old or < 50 years with other comorbidities, were enrolled to have a MOR or received standard pharmaceutical care. The primary outcome was the difference in the number of medicine-related problems (MRPs) between intervention and standard care groups at baseline and 6 months. Acceptability, cost of the intervention and health-related quality of life were also examined. RESULTS In all, 164 patients were analysed: 70 in the intervention group and 94 in the standard care group. A significant number of MRPs were detected in those patients receiving MOR compared with the standard care group at baseline (93 vs. 2; p = 0.001, z = -8.6, r = 0.6) and 6 months (33 vs. 3; p = 0.001, z = -5.7, r = 0.4). A significant reduction in the number of new MRPs at 6 months in the intervention group versus baseline was also observed (p = 0.001, Z = -3.7, r = 0.2); 44% of MRPs were fully resolved at baseline and 51% at 6 months. No changes in health-related quality of life following MOR or between MOR and standard care groups were observed. The MORs were highly acceptable among patients and healthcare professionals. CONCLUSIONS The MOR toolkit was feasible and acceptable, suggesting that HIV outpatient services might consider implementing MOR for targeted populations under their care.
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Affiliation(s)
- Heather A Leake Date
- University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, UK
| | - Katie Alford
- University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Natalia Hounsome
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - David Moore
- University Hospitals Sussex NHS Foundation Trust, Western Sussex Hospital, Worthing, UK
| | - Kin Ing
- University Hospitals Sussex NHS Foundation Trust, Western Sussex Hospital, Worthing, UK
| | - Jaime H Vera
- University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
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Marcum ZA, Jiang S, Bacci JL, Ruppar TM. Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis. J Am Geriatr Soc 2021; 69:3301-3311. [PMID: 34287846 DOI: 10.1111/jgs.17373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 06/26/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVE As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years). DESIGN/SETTING/PARTICIPANTS Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance. MEASUREMENTS Medication adherence using any method of measurement. RESULTS Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70). CONCLUSION This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.
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Affiliation(s)
- Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Shangqing Jiang
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Jennifer L Bacci
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Todd M Ruppar
- College of Nursing, Rush University, Chicago, Illinois, USA
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Tasai S, Kumpat N, Dilokthornsakul P, Chaiyakunapruk N, Saini B, Dhippayom T. Impact of Medication Reviews Delivered by Community Pharmacist to Elderly Patients on Polypharmacy: A Meta-analysis of Randomized Controlled Trials. J Patient Saf 2021; 17:290-298. [PMID: 30920431 DOI: 10.1097/pts.0000000000000599] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess the impact of medication reviews delivered by community pharmacists to elderly patients on polypharmacy. METHODS A systematic literature search was performed in four bibliographic databases/search engine (PubMed, Embase, CENTRAL, and IPA) and three gray literature sources (OpenGrey, ClinicalTrials.gov, and Digital Access to Research Theses - Europe) from inception to January 2018. Randomized controlled trials were selected if they met the following criteria: (a) studied in patients 65 years or older who were taking four or more prescribed medications; (b) the "test" interventions were delivered by community pharmacists; and (c) measured one of these following outcomes: hospitalization, emergency department (ED) visit, quality of life, or adherence. Quality of the included studies was assessed using the Cochrane Effective Practice and Organization of Care Group risk of bias tool. Random-effects model meta-analyses were performed. RESULTS Of the 3634 articles screened, four studies with a total of 4633 participants were included. The intervention provided in all included studies was clinical medication review. Three studies were at low risk of bias, and the remaining study had unclear risk of bias. When compared with usual care, medication reviews provided by community pharmacist significantly reduced risk of ED visits (risk ratio = 0.68; 95% confidence interval = 0.48-0.96). There was also a tendency that pharmacist interventions decreased risk of hospitalizations (risk ratio = 0.88; 95% CI = 0.78-1.00), although no statistical significant. CONCLUSIONS The current evidence demonstrates that clinical medication reviews for older people with polypharmacy reduces the risk of ED visits. Medication reviews can be considered as another area where community pharmacists can contribute to improve patient safety.
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Affiliation(s)
| | | | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | | | - Bandana Saini
- Sydney Pharmacy School, Faculties of Medicine and Health, the University of Sydney, Sydney, New South Wales, Australia
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Migliazza K, Bähler C, Liedtke D, Signorell A, Boes S, Blozik E. Potentially inappropriate medications and medication combinations before, during and after hospitalizations: an analysis of pathways and determinants in the Swiss healthcare setting. BMC Health Serv Res 2021; 21:522. [PMID: 34049550 PMCID: PMC8164287 DOI: 10.1186/s12913-021-06550-w] [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: 02/10/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background A hospitalization phase represents a challenge to medication safety especially for multimorbid patients as acute medical needs might interact with pre-existing medications or evoke adverse drug effects. This project aimed to examine the prevalence and risk factors of potentially inappropriate medications (PIMs) and medication combinations (PIMCs) in the context of hospitalizations. Methods Analyses are based on claims data of patients (≥65 years) with basic mandatory health insurance at the Helsana Group, and on data from the Hirslanden Swiss Hospital Group. We assessed PIMs and PIMCs of patients who were hospitalized in 2013 at three different time points (quarter prior, during, after hospitalization). PIMs were identified using the PRISCUS list, whereas PIMCs were derived from compendium.ch. Zero-inflated Poisson regression models were applied to determine risk factors of PIMs and PIMCs. Results Throughout the observation period, more than 80% of patients had at least one PIM, ranging from 49.7% in the pre-hospitalization, 53.6% in the hospitalization to 48.2% in the post-hospitalization period. PIMCs were found in 46.6% of patients prior to hospitalization, in 21.3% during hospitalization, and in 25.0% of patients after discharge. Additional medication prescriptions compared to the preceding period and increasing age were the main risk factors, whereas managed care was associated with a decrease in PIMs and PIMCs. Conclusion We conclude that a patient’s hospitalization offers the possibility to increase medication safety. Nevertheless, the prevalence of PIMs and PIMCs is relatively high in the study population. Therefore, our results indicate a need for interventions to increase medication safety in the Swiss healthcare setting.
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Affiliation(s)
- Kevin Migliazza
- Department of Health Sciences, Helsana Group, Zürich, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Group, Zürich, Switzerland
| | | | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zürich, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zürich, Switzerland. .,Institute of Primary Care, University of Zürich, Zürich, Switzerland.
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Pharmacist medication review: An integrated team approach to serve home-based primary care patients. PLoS One 2021; 16:e0252151. [PMID: 34033661 PMCID: PMC8148331 DOI: 10.1371/journal.pone.0252151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/11/2021] [Indexed: 11/19/2022] Open
Abstract
Background Comprehensive medication review is a patient-centered approach to optimize medication use and improve patient outcomes. This study outlines a pilot model of care in which a remote corporate-based clinical pharmacist implemented comprehensive medication reviews for a cohort of medically complex home-based primary care (HBPC) patients. Method Ninety-six medically complex patients were assessed for medication-related problems. Data collected on these patients were: number of chronic conditions, number of medications, appropriate indication for each medication, dose appropriateness, drug interactions, recommendations for medication optimization and deprescribing. The number of accepted recommendations by the HBPC practice was analyzed. Results On average, the patients were 82 years old and had 13 chronic conditions. They were taking a median of 17 medications. Over a four-month pilot period, 175 medication recommendations were made, and 53 (30.3%) of them were accepted, with most common being medication discontinuation, deprescribing, and dose adjustments. Sixty-four (66.7%) patients were on a medication listed as potentially inappropriate for use in older adults. The most common potentially inappropriate medication was a proton-pump inhibitor (38.5%), followed by aspirin (24%), tramadol (15.6%), a benzodiazepine (13.5%) or an opioid (8.3%). Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33.3%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (45.8%). Thirty-four medications were suggested as an addition to the current patient regimen, 2 medications were added (5.9%). Conclusion Pharmacist comprehensive medication review is a necessary component of the HBPC healthcare continuum. Additional research is needed to examine whether aligning pharmacists to deliver support to HBPC improves clinical outcomes, reduces healthcare expenditures and improves the patient’s experience.
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Gurwitz JH, Kapoor A, Garber L, Mazor KM, Wagner J, Cutrona SL, Singh S, Kanaan AO, Donovan JL, Crawford S, Anzuoni K, Konola TJ, Zhou Y, Field TS. Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:610-618. [PMID: 33646267 PMCID: PMC7922235 DOI: 10.1001/jamainternmed.2020.9285] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids. OBJECTIVE To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018. INTERVENTIONS The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail. MAIN OUTCOMES AND MEASURES The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome. RESULTS There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02781662.
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Affiliation(s)
- Jerry H Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester.,Reliant Medical Group, Worcester, Massachusetts
| | - Alok Kapoor
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Lawrence Garber
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Reliant Medical Group, Worcester, Massachusetts
| | - Kathleen M Mazor
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Joann Wagner
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Sarah L Cutrona
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sonal Singh
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Abir O Kanaan
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Massachusetts College of Pharmacy and Health Sciences, Worcester
| | - Jennifer L Donovan
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Sybil Crawford
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Kathryn Anzuoni
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Timothy J Konola
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Yanhua Zhou
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Terry S Field
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
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Cho J, Shin S, Jeong YM, Lee E, Lee E. The Effect of Regimen Frequency Simplification on Provider Order Generation: A Quasi-Experimental Study in a Korean Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084086. [PMID: 33924431 PMCID: PMC8070259 DOI: 10.3390/ijerph18084086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 11/16/2022]
Abstract
The multiplicity of dosing frequencies that are attached to medication orders poses a challenge to patients regarding adhering to their medication regimens and healthcare professionals in maximizing the efficiencies of health care service delivery. A multidisciplinary team project was performed to simplify medication regimens to improve the computerized physician order entry (CPOE) system to reduce the dosing frequencies for patients who were discharged from the hospital. A 36-month pre-test–post-test study was performed, including 12-month pre-intervention, 12-month intervention, and 12-month post-intervention periods. Two-pronged strategies, including regimen standardization and prioritization, were devised to evaluate the dosing frequencies and prescribing efficiency. The results showed that the standardized menu reduced the dosing frequencies from 4.3 ± 2.2 per day in the pre-intervention period to 3.5 ± 1.8 per day in the post-intervention period (p < 0.001). In addition, the proportion of patients taking medications five or more times per day decreased from 40.8% to 20.7% (p < 0.001). After prioritizing the CPOE dosing regimen, the number of pull-down options that were available reflected an improvement in the prescribing efficiency. Our findings indicate that concerted efforts in improving even a simple change on the CPOE screen via standardization and prioritization simplified the dosing frequencies for patients and improved the physicians’ prescribing process.
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Affiliation(s)
- Jungwon Cho
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (J.C.); (S.S.); (E.L.)
- College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
| | - Sangmi Shin
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (J.C.); (S.S.); (E.L.)
| | - Young Mi Jeong
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (J.C.); (S.S.); (E.L.)
- Correspondence: (Y.M.J.); (E.L.)
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (J.C.); (S.S.); (E.L.)
| | - Euni Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (J.C.); (S.S.); (E.L.)
- College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
- Correspondence: (Y.M.J.); (E.L.)
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Hanlon JT. Perspectives on geriatrics by pioneers in aging: Reflections of a clinical pharmacist. J Am Geriatr Soc 2021; 69:896-899. [PMID: 33559891 DOI: 10.1111/jgs.17052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Geriatric Research Education and Clinical Center/Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
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Lauffenburger JC, Isaac T, Trippa L, Keller P, Robertson T, Glynn RJ, Sequist TD, Kim DH, Fontanet CP, Castonguay EWB, Haff N, Barlev RA, Mahesri M, Gopalakrishnan C, Choudhry NK. Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol. Implement Sci 2021; 16:9. [PMID: 33413494 PMCID: PMC7792313 DOI: 10.1186/s13012-020-01078-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The prescribing of high-risk medications to older adults remains extremely common and results in potentially avoidable health consequences. Efforts to reduce prescribing have had limited success, in part because they have been sub-optimally timed, poorly designed, or not provided actionable information. Electronic health record (EHR)-based tools are commonly used but have had limited application in facilitating deprescribing in older adults. The objective is to determine whether designing EHR tools using behavioral science principles reduces inappropriate prescribing and clinical outcomes in older adults. METHODS The Novel Uses of Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) project uses a two-stage, 16-arm adaptive randomized pragmatic trial with a "pick-the-winner" design to identify the most effective of many potential EHR tools among primary care providers and their patients ≥ 65 years chronically using benzodiazepines, sedative hypnotic ("Z-drugs"), or anticholinergics in a large integrated delivery system. In stage 1, we randomized providers and their patients to usual care (n = 81 providers) or one of 15 EHR tools (n = 8 providers per arm) designed using behavioral principles including salience, choice architecture, or defaulting. After 6 months of follow-up, we will rank order the arms based upon their impact on the trial's primary outcome (for both stages): reduction in inappropriate prescribing (via discontinuation or tapering). In stage 2, we will randomize (a) stage 1 usual care providers in a 1:1 ratio to one of the up to 5 most promising stage 1 interventions or continue usual care and (b) stage 1 providers in the unselected arms in a 1:1 ratio to one of the 5 most promising interventions or usual care. Secondary and tertiary outcomes include quantities of medication prescribed and utilized and clinically significant adverse outcomes. DISCUSSION Stage 1 launched in October 2020. We plan to complete stage 2 follow-up in December 2021. These results will advance understanding about how behavioral science can optimize EHR decision support to improve prescribing and health outcomes. Adaptive trials have rarely been used in implementation science, so these findings also provide insight into how trials in this field could be more efficiently conducted. TRIAL REGISTRATION Clinicaltrials.gov ( NCT04284553 , registered: February 26, 2020).
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Affiliation(s)
- Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA. .,Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.
| | | | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Department of Biostatistics and Computational Biology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Punam Keller
- Tuck School of Business, Dartmouth College, Hanover, NH, USA
| | | | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Thomas D Sequist
- Division of General Internal Medicine and Department of Health Care Policy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dae H Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Constance P Fontanet
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.,Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | | | - Nancy Haff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.,Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Renee A Barlev
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.,Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Chandrashekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.,Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
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Syafhan NF, Al Azzam S, Williams SD, Wilson W, Brady J, Lawrence P, McCrudden M, Ahmed M, Scott MG, Fleming G, Hogg A, Scullin C, Horne R, Ahir H, McElnay JC. General practitioner practice-based pharmacist input to medicines optimisation in the UK: pragmatic, multicenter, randomised, controlled trial. J Pharm Policy Pract 2021; 14:4. [PMID: 33397509 PMCID: PMC7784025 DOI: 10.1186/s40545-020-00279-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Changing demographics across the UK has led to general practitioners (GPs) managing increasing numbers of older patients with multi-morbidity and resultant polypharmacy. Through government led initiatives within the National Health Service, an increasing number of GP practices employ pharmacist support. The purpose of this study is to evaluate the impact of a medicines optimisation intervention, delivered by GP practice-based pharmacists, to patients at risk of medication-related problems (MRPs), on patient outcomes and healthcare costs. METHODS A multi-centre, randomised (normal care or pharmacist supplemented care) study in four regions of the UK, involving patients (n = 356) from eight GP practices, with a 6-month follow-up period. Participants were adult patients who were at risk of MRPs. RESULTS Median number of MRPs per intervention patient were reduced at the third assessment, i.e. 3 to 0.5 (p < 0.001) in patients who received the full intervention schedule. Medication Appropriateness Index (MAI) scores were reduced (medications more appropriate) for the intervention group, but not for control group patients (8 [4-13] to 5 [0-11] vs 8 [3-13] to 7 [3-12], respectively; p = 0.001). Using the intention-to-treat (ITT) approach, the number of telephone consultations in intervention group patients was reduced and different from the control group (1 [0-3] to 1 [0-2] vs 1 [0-2] to 1 [0-3], p = 0.020). No significant differences between groups were, however, found in unplanned hospital admissions, length of hospital stay, number of A&E attendances or outpatient visits. The mean overall healthcare cost per intervention patient fell from £1041.7 ± 1446.7 to £859.1 ± 1235.2 (p = 0.032). Cost utility analysis showed an incremental cost per patient of - £229.0 (95% CI - 594.6, 128.2) and a mean QALY gained of 0.024 (95% CI - 0.021 to 0.065), i.e. indicative of a health status gain at a reduced cost (2016/2017). CONCLUSION The pharmacist service was effective in reducing MRPs, inappropriateness of medications and telephone consultations in general practice in a cost-effective manner. TRIAL REGISTRATION ClinicalTrials.Gov, NCT03241498. Registered 7 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03241498.
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Affiliation(s)
- Nadia Farhanah Syafhan
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | - Sayer Al Azzam
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | | | | | | | - Mustafa Ahmed
- Fern House Surgery, Essex, UK
- Douglas Grove Surgery, Essex, UK
| | | | - Glenda Fleming
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Anita Hogg
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Claire Scullin
- Medicines Optimisation Innovation Centre (MOIC), Antrim, UK
| | - Robert Horne
- School of Pharmacy, University College London, London, UK
| | | | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, UK.
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Leblanc MM, Daley K, Pickel K, Zaets L. Prescriber Acceptance of Pharmacist-Written Recommendations in a Home-Based Primary Care Setting at a Veterans Affairs Healthcare System. Sr Care Pharm 2021; 36:56-62. [PMID: 33384035 DOI: 10.4140/tcp.n.2021.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To assess prescriber acceptance of pharmacist-written recommendations and to identify areas of improvement for implementing and tracking pharmacist-written reviews.DESIGN: Phase one was a retrospective study to evaluate prescriber acceptance of pharmacist-written recommendations. Phase two consisted of the distribution of a brief anonymous survey for prescribers to provide input on preferences for pharmacist-written recommendations.SETTING: Patients receiving Home-Based Primary Care (HBPC) services at VA Connecticut Healthcare System. PARTICIPANTS: Fifty veterans admitted to the HBPC program from January 2019 to April 2019 with at least 3 months of follow-up per patient.MAIN OUTCOME MEASURE: The primary outcome was the prescriber acceptance rate of HBPC pharmacistwritten recommendations.RESULTS: Out of 194 total pharmacist-written recommendations documented, 40.2% were accepted by providers. Specialty providers accepted a higher percentage of recommendations than primary care providers. Recommendations had a higher acceptance rate when both an attending provider and trainee were alerted (63.0%) versus an attending alone (36.1%). The anonymous survey concluded the majority of providers appreciate short, direct, clinically relevant summary recommendations.CONCLUSION: Overall, approximately 40% of the pharmacist-written recommendations were accepted and 66.7% were appropriately tracked, demonstrating there are opportunities for improvement. Formulating short, focused, and direct recommendations as well as ensuring to alert both attendings and trainees when indicated may optimize acceptance rates. Further research with a larger sample size is still needed to assess the barriers to prescriber acceptance of pharmacist-written recommendations.
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Affiliation(s)
- Micaela M Leblanc
- 1PGY2 Geriatric Pharmacy Resident; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kim Daley
- 2Home-Based Primary Care Clinical Pharmacy Specialist, VA Connecticut Healthcare System, Newington, Connecticut
| | - Karen Pickel
- 2Home-Based Primary Care Clinical Pharmacy Specialist, VA Connecticut Healthcare System, Newington, Connecticut
| | - Lauren Zaets
- 2Home-Based Primary Care Clinical Pharmacy Specialist, VA Connecticut Healthcare System, Newington, Connecticut
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Zechmann S, Senn O, Valeri F, Essig S, Merlo C, Rosemann T, Neuner-Jehle S. Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial. BMC Geriatr 2020; 20:471. [PMID: 33198634 PMCID: PMC7670707 DOI: 10.1186/s12877-020-01870-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
Background Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients. Methods This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures. Results Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures. Conclusion Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success. Trial registration Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014. The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01870-8.
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Affiliation(s)
- Stefan Zechmann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Essig
- Institute of Primary and Community Care, Lucerne, Switzerland
| | - Christoph Merlo
- Institute of Primary and Community Care, Lucerne, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
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Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study. Sci Rep 2020; 10:18964. [PMID: 33144598 PMCID: PMC7609640 DOI: 10.1038/s41598-020-75888-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
Polypharmacy is a growing and major public health issue, particularly in the geriatric population. This study aimed to examine the association between polypharmacy and the risk of hospitalization and mortality. We included 3,007,620 elderly individuals aged ≥ 65 years who had at least one routinely-prescribed medication but had no prior hospitalization within a year. The primary exposures of interest were number of daily prescribed medications (1–2, 3–4, 5–6, 7–8, 9–10, and ≥ 11) and presence of polypharmacy (≥ 5 prescription drugs per day). The corresponding comparators were the lowest number of medications (1–2) and absence of polypharmacy. The study outcomes were hospitalization and all-cause death. The median age of participants was 72 years and 39.5% were men. Approximately, 46.6% of participants experienced polypharmacy. Over a median follow-up of 5.0 years, 2,028,062 (67.4%) hospitalizations and 459,076 (15.3%) all-cause deaths were observed. An incrementally higher number of daily prescribed medications was found to be associated with increasingly higher risk for hospitalization and mortality. These associations were consistent across subgroups of age, sex, residential area, and comorbidities. Furthermore, polypharmacy was associated with greater risk of hospitalization and death: adjusted HRs (95% CIs) were 1.18 (1.18–1.19) and 1.25 (1.24–1.25) in the overall and 1.16 (1.16–1.17) and 1.25 (1.24–1.25) in the matched cohorts, respectively. Hence, polypharmacy was associated with a higher risk of hospitalization and all-cause death among elderly individuals.
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Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:3323-3332. [PMID: 32820421 PMCID: PMC7661661 DOI: 10.1007/s11606-020-06089-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/29/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION PROSPERO - CRD42019132420.
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Affiliation(s)
- Hanna E Bloomfield
- Minneapolis VA Health Care System, Minneapolis, USA.
- University of Minnesota School of Medicine, Minneapolis, USA.
- Minneapolis VA Medical Center (151), 1 Veterans Drive, Minneapolis, MN, 55417, USA.
| | - Nancy Greer
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Amy M Linsky
- VA Boston Healthcare System and Boston University School of Medicine, Boston, USA
| | | | - Todd Naidl
- Minneapolis VA Health Care System, Minneapolis, USA
| | - Orly Vardeny
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Lauren McKenzie
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
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Baumgartner A, Kunkes T, Clark CM, Brady LA, Monte SV, Singh R, Wahler RG, Chen HYW. Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy. JMIR Hum Factors 2020; 7:e18103. [PMID: 32788157 PMCID: PMC7453327 DOI: 10.2196/18103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/12/2023] Open
Abstract
Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.
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Affiliation(s)
- Andrew Baumgartner
- Department of Family Medicine, University at Buffalo, State University of New York, Buffalo, NY, United States
| | - Taylor Kunkes
- Department of Industrial and Systems Engineering, School of Engineering and Applied Sciences, University at Buffalo, Buffalo, NY, United States
| | - Collin M Clark
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Laura A Brady
- Department of Family Medicine, Primary Care Research Institute, State University of New York at Buffalo, Buffalo, NY, United States
| | - Scott V Monte
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Ranjit Singh
- Department of Family Medicine, Primary Care Research Institute, State University of New York at Buffalo, Buffalo, NY, United States
| | - Robert G Wahler
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Huei-Yen Winnie Chen
- Department of Industrial and Systems Engineering, School of Engineering and Applied Sciences, University at Buffalo, Buffalo, NY, United States
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Cadogan CA, Rankin A, Lewin S, Hughes CM. Application of the intervention Complexity Assessment Tool for Systematic Reviews within a Cochrane review: an illustrative case study. HRB Open Res 2020; 3:31. [PMID: 32596632 PMCID: PMC7309054 DOI: 10.12688/hrbopenres.13044.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background: The intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) has been developed to facilitate detailed assessments of intervention complexity in systematic reviews. Worked examples of the tool’s application are needed to promote its use and refinement. The aim of this case study was to apply the iCAT_SR to a subset of 20 studies included in a Cochrane review of interventions aimed at improving appropriate polypharmacy in older people. Methods: Interventions were assessed independently by two authors using the six core iCAT_SR dimensions: (1) ‘Target organisational levels/categories’; (2) ‘Target behaviour/actions’; (3) ‘Active intervention components’; (4) ‘Degree of tailoring’; (5) ‘Level of skill required by intervention deliverers’; (6) ‘Level of skill required by intervention recipients’. Attempts were made to apply four optional dimensions: ‘Interaction between intervention components’; ‘Context/setting’; ‘Recipient/provider factors’; ‘Nature of causal pathway’. Inter-rater reliability was assessed using Cohen’s Kappa coefficient. Disagreements were resolved by consensus discussion. The findings are presented narratively. Results: Assessments involving the core iCAT_SR dimensions showed limited consistency in intervention complexity across included studies, even when categorised according to clinical setting. Interventions were delivered across various organisational levels and categories (i.e. healthcare professionals and patients) and typically comprised multiple components. Intermediate skill levels were required by those delivering and receiving the interventions across all studies. A lack of detail in study reports precluded application of the iCAT_SR’s optional dimensions. The inter-rater reliability was substantial (Cohen's Kappa = 0.75) Conclusions: This study describes the application of the iCAT_SR to studies included in a Cochrane systematic review. Future intervention studies need to ensure more detailed reporting of interventions, context and the causal pathways underlying intervention effects to allow a more holistic understanding of intervention complexity and facilitate replication in other settings. The experience gained has helped to refine the original guidance document relating to the application of iCAT_SR.
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Affiliation(s)
- Cathal A Cadogan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway.,Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. J Am Pharm Assoc (2003) 2020; 60:e86-e92. [DOI: 10.1016/j.japh.2020.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 11/23/2022]
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Interventions to Reduce Adverse Drug Event-Related Outcomes in Older Adults: A Systematic Review and Meta-analysis. Drugs Aging 2020; 37:91-98. [PMID: 31919801 DOI: 10.1007/s40266-019-00738-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many studies focus on interventions that reduce the processes that lead to adverse drug events (ADEs), such as inappropriate or high-risk prescribing, without assessing whether they result in a reduction in ADEs or associated adverse health outcomes. OBJECTIVES Our objective was to systematically review interventions to reduce the incidence of ADEs measured by health outcomes in older patients in primary care settings. METHODS The review included randomised controlled trials, controlled clinical trials, controlled before and after studies, interrupted time series studies and cohort studies conducted in the community care setting. Older patients (aged ≥ 65 years) receiving medical treatment in primary care were included. Interventions were aimed at reducing adverse health outcomes associated with ADEs in older patients. Risk of bias was assessed using the Cochrane Collaboration's tool. Outcomes were measured by reductions in hospitalisation, emergency department (ED) visits, mortality and improvements in quality of life (QoL), mental health and physical function. Fixed and random-effects models were used to calculate pooled effect estimates comparing interventions and control groups for the outcomes, where feasible. RESULTS The literature search identified 1566 abstracts, seven of which were included in the systematic review. The interventions for reducing ADEs included prescription or medication reviews by a pharmacist (n = 4), primary care physician (n = 1) or research team (n = 1), and an educational intervention (n = 1) for nursing staff to improve the recognition of potentially harmful medications and corresponding ADEs. Meta-analysis found no statistically significant benefit from any interventions on hospitalisation, ED visits, mortality, QoL or mental health and physical function. CONCLUSIONS No significant benefit was gained from any of the interventions in terms of the outcomes considered. New approaches are required to reduce ADEs in older adults.
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Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Syst Rev 2020; 5:CD012419. [PMID: 32383493 PMCID: PMC7207012 DOI: 10.1002/14651858.cd012419.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications. OBJECTIVES To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications. SEARCH METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality. MAIN RESULTS We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes. AUTHORS' CONCLUSIONS Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Austin Health, Heidelberg, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Lisha Kuruvilla
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Barwon Health, North Geelong, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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Abstract
AbstractThis article examines how older adults make decisions about their medications through interconnected axes of trust that operate across social networks. Trust is negotiated by older adults enrolled in a deprescribing programme which guides them through the process of reducing medications to mitigate risks associated with polypharmacy. Habermas’ work on the significance of communicative action in negotiating trust within social relationships informs our analysis, specifically in-depth semi-structured interviews with older adults about their medication use and the role of social networks in managing their health. Participants were age 70+ and experiencing polypharmacy. Our analysis discusses the social nature of medication practices and the importance of social networks for older adults’ decision-making. Their perspective reflects the critique of late-modern society put forward by Habermas. Negotiating trust in pharmaceutical decision-making requires navigating tensions across and between system networks (health-care professionals) and life-world networks (family and friends). This study contributes to our knowledge of how distinct forms of trust operate in different social spheres, setting the context for the way health-care decisions are made across social networks. Our analysis reinforces the need for older adults to engage meaningfully in health-care decision-making such that a convergence between system-world and life-world structures is encouraged. This would improve deprescribing programmes’ efficacy as older adults optimise their medication use and improve overall quality of life.
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