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Meyer-Junco L. Time to Deprescribe: A Time-Centric Model for Deprescribing at End of Life. J Palliat Med 2020; 24:273-284. [PMID: 33226878 DOI: 10.1089/jpm.2020.0430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In end-of-life care, deprescribing practices may vary considerably from one practitioner to the next, although most published frameworks for evaluating medication appropriateness in advanced illness consider three key principles (1) patient and caregiver goals, (2) remaining life expectancy (LE), and (3) medication time to benefit (TTB). The objective of this article is to provide clinicians with a structured, consistent approach for deprescribing that does not replace clinical judgment or the preferences of patients and their families but enhances it through clinical data. The emphasis will be on the time component of published models, including how to estimate remaining LE and medication TTB. Through case examples of two new hospice admissions, LE and TTB will be estimated and applied to deprescribing decisions. This time-centric approach may satisfy the palliative and hospice clinicians' desire for clear clinical justification for medication discontinuation while at the same time providing a strategy for communicating deprescribing rationale to patients and families.
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Affiliation(s)
- Laura Meyer-Junco
- Hospice, Palliative Care, and Geriatrics, University of Illinois at Chicago (UIC) College of Pharmacy, Rockford, Illinois, USA
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2
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Campitelli MA, Maxwell CJ, Giannakeas V, Bell CM, Daneman N, Jeffs L, Morris AM, Austin PC, Hogan DB, Ko DT, Lapane KL, Maclagan LC, Seitz DP, Bronskill SE. The Variation of Statin Use Among Nursing Home Residents and Physicians: A Cross-Sectional Analysis. J Am Geriatr Soc 2017; 65:2044-2051. [PMID: 28791683 DOI: 10.1111/jgs.15013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine the variability of statin use among nursing home residents and prescribing physicians, and to assess statin use by resident frailty. DESIGN Population-based, cross-sectional analysis. SETTING All nursing home facilities (N = 631) in Ontario, Canada between April 1, 2013 and March 31, 2014. PARTICIPANTS All adults aged 66 years and older who received a full clinical assessment while residing in a nursing home facility and their assigned, most responsible, physician. MEASUREMENTS Statin use on date of clinical assessment. Resident- and physician-level characteristics ascertained through clinical assessment and health administrative data. Resident frailty was derived using a previously validated index. RESULTS Among 76,226 nursing home residents assigned to 1,919 physicians, 25,648 (33.6%) were statin users. There were 13,331 (30.1%) statin users among the 44,290 residents categorized as frail. In an adjusted mixed-effects logistic regression model, frail residents (adjusted odds ratio = 0.62, 95% confidence interval 0.58-0.65) were significantly less likely to be statin users compared with non-frail residents. After adjustment for resident characteristics, the intraclass correlation coefficient indicated that between-physician variability accounted for 9.1% of the residual unexplained variation in statin use (P < .001). Among the 894 physicians assigned 20 or more residents, funnel plots confirmed there were more low-outlying (17.4%) and high-outlying (12.0%) prescribers of statins than expected by chance. Physicians who were high-outlying prescribers had higher historical rates of statin prescribing. CONCLUSIONS AND RELEVANCE Statin prescribing was substantial within nursing homes, even among frail residents. After controlling for resident characteristics, the likelihood of statin prescribing varied significantly across physicians. Further studies are required to evaluate the risks and benefits of statin use, and discontinuation, among nursing home residents to better inform clinical practice in this setting.
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Affiliation(s)
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Vasily Giannakeas
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nick Daneman
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lianne Jeffs
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Andrew M Morris
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David B Hogan
- Divison of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worchester, Massachusetts
| | - Laura C Maclagan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Dallas P Seitz
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Abstract
As older adults age, it is imperative to constantly reevaluate medications. Deprescribing, the process of identifying and discontinuing drugs that could potentially harm rather than benefit a patient, should therefore be considered in all older adults on an individual basis. Nurses are a critical part of the team in addressing this issue. The current article discusses deprescribing, tactics to this approach, and important areas for future development.
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Tran NN, DiScala SL, Mandi D, Pavlides AC, Marks S, Silverman MA. Discontinuation of Statins at the End of Life #322. J Palliat Med 2017; 20:199-200. [DOI: 10.1089/jpm.2016.0436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cortis LJ. A qualitative study to describe patient-specific factors that relate to clinical need for and potential to benefit from a medication management service in palliative care. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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6
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Jansen J, McKinn S, Bonner C, Irwig L, Doust J, Glasziou P, Bell K, Naganathan V, McCaffery K. General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study. PLoS One 2017; 12:e0170228. [PMID: 28085944 PMCID: PMC5234831 DOI: 10.1371/journal.pone.0170228] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older. METHOD 25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used. RESULTS Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear. CONCLUSION Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.
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Affiliation(s)
- Jesse Jansen
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
| | - Shannon McKinn
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Paul Glasziou
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Katy Bell
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Ageing and Alzheimer’s Institute, Concord Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
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7
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Victoria K, Patel S. The Palliative Care Information Act and Access to Palliative Care in Terminally ill Patients: A Retrospective Study. Indian J Palliat Care 2016; 22:427-431. [PMID: 27803564 PMCID: PMC5072234 DOI: 10.4103/0973-1075.191774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Studies have shown that over 50% of end-of-life discussions take place for the first time in the hospital and that terminally ill patients often have unrealistic views regarding the possible scope of treatment. The Palliative Care information Act (PCIA) was passed in an attempt to address the lack of access for terminally ill patients to palliative care services. A multi-database systematic review was performed on published studies from 2010 to present, and there were none found measuring the effectiveness of the PCIA. Objectives: We aimed to study the effect of the PCIA on access to palliative care services. Methods: We conducted a retrospective chart review of all terminally ill patients who died at Kingsbrook Jewish Medical Center from January 2010 to August 2013 in relation to passing of the PCIA. Results: Prelaw (prior to the law passing), 12.3% of the terminal patients received palliative care consults, 25% during the transition period (time between passing of law and when it came into effect) and 37.7% postlaw (after coming into effect) (P < 0.001). Conclusions: Legislation can have a significant effect on terminally ill patient's access to palliative care services and can change the culture of a hospital to be more pro-palliative for the appropriate populations.
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Affiliation(s)
- Kitty Victoria
- Department of Medicine, New York Methodist Hospital, Brooklyn, New York, USA
| | - Sarita Patel
- Department of Palliative Care Services, Kingsbrook Jewish Hospital, Brooklyn, New York, USA
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Abstract
BACKGROUND There are approximately 24 million people worldwide with dementia; this is likely to increase to 81 million by 2040. Dementia is a progressive condition, and usually leads to death eight to ten years after first symptoms. End-of-life care should emphasise treatments that optimise quality of life and physicians should minimise unnecessary or non-beneficial interventions. Statins are 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors; they have become the cornerstone of pharmacotherapy for the management of hypercholesterolaemia but their ability to provide benefit is unclear in the last weeks or months of life. Withdrawal of statins may improve quality of life in people with advanced dementia, as they will not be subjected to unnecessary polypharmacy or side effects. However, they may help to prevent further vascular events in people of advanced age who are at high risk of such events. OBJECTIVES To evaluate the effects of withdrawal or continuation of statins in people with dementia on: cognitive outcomes, adverse events, behavioural and functional outcomes, mortality, quality of life, vascular morbidity, and healthcare costs. SEARCH METHODS We searched ALOIS (medicine.ox.ac.uk/alois/), the Cochrane Dementia and Cognitive Improvement Group Specialised Register on 11 February 2016. We also ran additional searches in MEDLINE, EMBASE, PsycINFO, CINAHL, Clinical.Trials.gov and the WHO Portal/ICTRP on 11 February 2016, to ensure that the searches were as comprehensive and as up-to-date as possible. SELECTION CRITERIA We included all randomised, controlled clinical trials with either a placebo or 'no treatment' control group. We applied no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, using standard methodological procedures expected by Cochrane. We found no studies suitable for inclusion therefore analysed no data. MAIN RESULTS The search strategy identified 28 unique references, all of which were excluded. AUTHORS' CONCLUSIONS We found no evidence to enable us to make an informed decision about statin withdrawal in dementia. Randomised controlled studies need to be conducted to assess cognitive and other effects of statins in participants with dementia, especially when the disease is advanced.
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Affiliation(s)
- Bernadette McGuinness
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block BGrosvenor RoadBelfastCo AntrimUKBT12 6BA
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block BGrosvenor RoadBelfastCo AntrimUKBT12 6BA
| | - Peter Passmore
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block BGrosvenor RoadBelfastCo AntrimUKBT12 6BA
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LeBlanc TW, Kutner JS, Ko D, Wheeler JL, Bull J, Abernethy AP. Developing the evidence base for palliative care: formation of the Palliative Care Research Cooperative and its first trial. Hosp Pract (1995) 2016; 38:137-43. [PMID: 20890063 DOI: 10.3810/hp.2010.06.320] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The field of palliative care and hospice has gained accreditation, with a growing cadre of specialists being trained, but there is a dearth of robust research evidence to guide clinical practice. After 2 years of planning, a group of senior investigators convened in January 2010 to explore the possibility of forming a research cooperative group dedicated to advancing the evidence base in palliative care and hospice. The meeting launched the Palliative Care Research Cooperative (PCRC) with an initial national/international membership, and a plan for developing policies and procedures. Proof of the concept for the PCRC is being established through the design, conduct, and dissemination of a multi-site clinical trial targeting a consensually selected, clinically relevant research question: Should patients who are taking statins for primary or secondary prevention, and who have a prognosis of < 6 months, discontinue these medications? A core group of PCRC members have developed the flagship study for the PCRC, evaluating the discontinuation of statin medications in the palliative care setting. Using the proposed trial as a case study, we underscore several approaches to overcoming common research challenges in end-of-life settings, including: 1) study design, to ensure feasibility and timeliness; 2) strategies to overcome barriers to research in this population; 3) data collection and management, to reduce the burden on patients, caregivers, research personnel, and sites while maximizing quality and efficiency; and 4) agenda setting. This article describes the rationale for convening the PCRC and highlights core principles for developing the evidence base in palliative medicine.
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Affiliation(s)
- Thomas W LeBlanc
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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10
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Kutner JS, Blatchford PJ, Taylor DH, Ritchie CS, Bull JH, Fairclough DL, Hanson LC, LeBlanc TW, Samsa GP, Wolf S, Aziz NM, Currow DC, Ferrell B, Wagner-Johnston N, Zafar SY, Cleary JF, Dev S, Goode PS, Kamal AH, Kassner C, Kvale EA, McCallum JG, Ogunseitan AB, Pantilat SZ, Portenoy RK, Prince-Paul M, Sloan JA, Swetz KM, Von Gunten CF, Abernethy AP. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015; 175:691-700. [PMID: 25798575 PMCID: PMC4618294 DOI: 10.1001/jamainternmed.2015.0289] [Citation(s) in RCA: 357] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.
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Affiliation(s)
- Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Christine S Ritchie
- San Francisco Veterans Affairs Medical Center, Center for Research on Aging, Jewish Home of San Francisco, San Francisco, California5Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Janet H Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Diane L Fairclough
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill
| | - Thomas W LeBlanc
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Greg P Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - David C Currow
- Discipline, Palliative, and Supportive Services, Flinders University, Adelaide, Australia
| | - Betty Ferrell
- Department of Nursing Research, City of Hope Medical Center, City of Hope, California
| | | | - S Yousuf Zafar
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - James F Cleary
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Sandesh Dev
- Department of Medicine, Phoenix Veterans Affairs Health Care System, Phoenix, Arizona
| | - Patricia S Goode
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Arif H Kamal
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Elizabeth A Kvale
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | | | - Adeboye B Ogunseitan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Russell K Portenoy
- Metropolitan Jewish Health System, Hospice and Palliative Care, New York, New York
| | - Maryjo Prince-Paul
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Jeff A Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Amy P Abernethy
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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11
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Statin use in cancer patients with brain metastases: a missed communication opportunity at the end of life. Support Care Cancer 2015; 23:2643-8. [DOI: 10.1007/s00520-015-2624-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/22/2015] [Indexed: 10/24/2022]
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12
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Russell BJ, Rowett D, Abernethy AP, Currow DC. Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications. Intern Med J 2015; 44:177-84. [PMID: 24341863 DOI: 10.1111/imj.12340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/05/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects. AIM To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications. METHODS A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden. RESULTS Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile. CONCLUSIONS Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.
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Affiliation(s)
- B J Russell
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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13
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Hanson LC, Bull J, Wessell K, Massie L, Bennett RE, Kutner JS, Aziz NM, Abernethy A. Strategies to support recruitment of patients with life-limiting illness for research: the Palliative Care Research Cooperative Group. J Pain Symptom Manage 2014; 48:1021-30. [PMID: 24863152 PMCID: PMC4241388 DOI: 10.1016/j.jpainsymman.2014.04.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/31/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT The Palliative Care Research Cooperative Group (PCRC) is the first clinical trials cooperative for palliative care in the U.S. OBJECTIVES To describe barriers and strategies for recruitment during the inaugural PCRC clinical trial. METHODS The parent study was a multisite randomized controlled trial enrolling adults with life expectancy anticipated to be one to six months, randomized to discontinue statins (intervention) vs. to continue on statins (control). To study recruitment best practices, we conducted semistructured interviews with 18 site principal investigators (PIs) and clinical research coordinators (CRCs) and reviewed recruitment rates. Interviews covered three topics: 1) successful strategies for recruitment, 2) barriers to recruitment, and 3) optimal roles of the PI and CRC. RESULTS All eligible site PIs and CRCs completed interviews and provided data on statin protocol recruitment. The parent study completed recruitment of 381 patients. Site enrollment ranged from 1 to 109 participants, with an average of 25 enrolled per site. Five major barriers included difficulty locating eligible patients, severity of illness, family and provider protectiveness, seeking patients in multiple settings, and lack of resources for recruitment activities. Five effective recruitment strategies included systematic screening of patient lists, thoughtful messaging to make research relevant, flexible protocols to accommodate patients' needs, support from clinical champions, and the additional resources of a trials cooperative group. CONCLUSION The recruitment experience from the multisite PCRC yields new insights into methods for effective recruitment to palliative care clinical trials. These results will inform training materials for the PCRC and may assist other investigators in the field.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA; Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Janet Bull
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, USA
| | - Kathryn Wessell
- Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lisa Massie
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, USA
| | - Rachael E Bennett
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Amy Abernethy
- Division of Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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In patients receiving end-of-life care, medications used to treat co-morbid diseases should be discontinued when appropriate. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tjia J, Cutrona SL, Peterson D, Reed G, Andrade SE, Mitchell SL. Statin discontinuation in nursing home residents with advanced dementia. J Am Geriatr Soc 2014; 62:2095-101. [PMID: 25369872 PMCID: PMC4241149 DOI: 10.1111/jgs.13105] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days. DESIGN Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files. SETTING All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida). PARTICIPANTS NH residents with dementia. MEASUREMENTS Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation. RESULTS Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication. CONCLUSION Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, Worcester, MA
| | | | | | - George Reed
- University of Massachusetts Medical School, Worcester, MA
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Turner JP, Shakib S, Singhal N, Hogan-Doran J, Prowse R, Johns S, Thynne T, Bell JS. Statin use and pain in older people with cancer: a cross-sectional study. J Am Geriatr Soc 2014; 62:1900-5. [PMID: 25284040 DOI: 10.1111/jgs.13051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate statin use and pain in people with cancer aged 70 to 79 and 80 and older. DESIGN Cross-sectional. SETTING Medical oncology outpatient clinic at the Royal Adelaide Hospital. PARTICIPANTS Individuals aged 70 and older who presented consecutively between January 2009 and June 2010 (n = 385), of whom 106 were aged 80 and older. MEASUREMENTS Participants completed a structured data collection instrument, documenting medication use, comorbidities and a general pain assessment (10-point visual analogue scale (VAS)). Unadjusted and adjusted logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with statin use. RESULTS The prevalence of statin use was 35% (n = 97) in people aged 70 to 79 and 39% (n = 41) in those aged 80 and older. After adjusting for age, sex, Charlson Comorbidity Index, and analgesic use, statin use was associated with self-reported pain (VAS ≥ 5) (OR = 4.09, 95% CI = 1.32-12.68) in people aged 80 and older but not in those aged 70 to 79. Half of participants using statins (51% n = 70) had a palliative treatment approach. Of the 41 statin users aged 80 and older, 20 (49%) were using statins for primary prevention. CONCLUSION The prevalence of statin use was similar in people aged 70 to 79 years and those aged 80 and older, with statin use associated with self-reported pain in people aged 80 and older. This highlights a potential benefit of "deprescribing" statins in older people with cancer, especially those aged 80 and older.
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Affiliation(s)
- Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia; Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Holmes HM, Min LC, Yee M, Varadhan R, Basran J, Dale W, Boyd CM. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging 2014; 30:655-66. [PMID: 23749475 DOI: 10.1007/s40266-013-0095-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.
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Affiliation(s)
- Holly M Holmes
- Department of General Internal Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA.
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van Nordennen RTCM, Lavrijsen JCM, Vissers KCP, Koopmans RTCM. Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review. Drugs Aging 2014; 31:501-12. [DOI: 10.1007/s40266-014-0182-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Parsons C, McCorry N, Murphy K, Byrne S, O'Sullivan D, O'Mahony D, Passmore P, Patterson S, Hughes C. Assessment of factors that influence physician decision making regarding medication use in patients with dementia at the end of life. Int J Geriatr Psychiatry 2014; 29:281-90. [PMID: 23836439 DOI: 10.1002/gps.4006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 06/13/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study aimed to evaluate the extent to which patient-related factors and physicians' country of practice (Northern Ireland [NI] and the Republic of Ireland [RoI]) influenced decision making regarding medication use in patients with end-stage dementia. METHODS The study utilised a factorial survey design comprising four vignettes to evaluate initiating/withholding or continuing/discontinuing specific medications in patients with dementia nearing death. Questionnaires and vignettes were mailed to all hospital physicians in geriatric medicine and to all general practitioners (GPs) in NI (November 2010) and RoI (December 2010), with a second copy provided 3 weeks after the first mailing. Logistic regression models were constructed to examine the impact of patient-related factors and physicians' country of practice on decision making. Significance was set a priori at p ≤ 0.05. Free text responses to open questions were analysed qualitatively using content analysis. RESULTS The response rate was 20.6% (N = 662) [21.1% (N = 245) for GPs and 52.1% (N = 38) for hospital physicians in NI, 18.3% (N = 348) for GPs and 36.0% (N = 31) for hospital physicians in RoI]. There was considerable variability in decision making about initiating/withholding antibiotics and continuing/discontinuing the acetylcholinesterase inhibitor and memantine hydrochloride, and less variability in decision making regarding statins and antipsychotics. Patient place of residence and physician's country of practice had the strongest and most consistent effects on decision making although effect sizes were small. CONCLUSIONS Further research is required into other factors that may impact upon physicians' prescribing decisions for these vulnerable patients and to clarify how the factors examined in this study influence prescribing decisions.
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Affiliation(s)
- Carole Parsons
- Clinical & Practice Research Group, School of Pharmacy, Queen's University Belfast, UK
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Lee HR, Yi SY, Kim DY. Evaluation of Prescribing Medications for Terminal Cancer Patients near Death: Essential or Futile. Cancer Res Treat 2013; 45:220-5. [PMID: 24155681 PMCID: PMC3804734 DOI: 10.4143/crt.2013.45.3.220] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 06/04/2013] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission. MATERIALS AND METHODS We conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated. RESULTS A total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile. CONCLUSION Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.
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Affiliation(s)
- Hye Ran Lee
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Maddison AR, Fisher J, Johnston G. Preventive medication use among persons with limited life expectancy. PROGRESS IN PALLIATIVE CARE 2013; 19:15-21. [PMID: 21731193 PMCID: PMC3118532 DOI: 10.1179/174329111x576698] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Persons with limited life expectancy (LLE) – less than 1 year – are significant consumers of health care, are at increased risk of polypharmacy and adverse drug events, and have dynamic health statuses. Therefore, medication use among this population must be appropriate and regularly evaluated. The objective of this review is to assess the current state of knowledge and clinical practice presented in the literature regarding preventive medication use among persons with LLE. We searched Medline, Embase, and CINAHL using Medical Subject Headings. Broad searches were first conducted using the terms ‘terminal care or therapy’ or ‘advanced disease’ and ‘polypharmacy’ or ‘inappropriate medication’ or ‘preventive medicine’, followed by more specific searches using the terms ‘statins’ or ‘anti-hypertensives’ or ‘bisphosphonates’ or ‘laxatives’ and ‘terminal care’. Frameworks to assess appropriate versus inappropriate medications for persons with LLE, and the prevalence of potentially inappropriate medication use among this population, are presented. A considerable proportion of individuals with a known terminal condition continue to take chronic disease preventive medications until death despite questionable benefit. The addition of palliative preventive medications is advised. There is an indication that as death approaches the shift from a curative to palliative goal of care translates into a shift in medication use. This literature review is a first step towards improving medication use and decreasing polypharmacy in persons at the end of life. There is a need to develop consensus criteria to assess appropriate versus inappropriate medication use, specifically for individuals at the end of life.
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Affiliation(s)
- André R Maddison
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Bayliss EA, Bronsert MR, Reifler LM, Ellis JL, Steiner JF, McQuillen DB, Fairclough DL. Statin prescribing patterns in a cohort of cancer patients with poor prognosis. J Palliat Med 2013; 16:412-8. [PMID: 23305190 DOI: 10.1089/jpm.2012.0158] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are no evidence-based recommendations for statin continuation or discontinuation near the end of life. However, some expert opinion recommends continuing statins prescribed for secondary versus primary prevention of cardiovascular disease. OBJECTIVES Our aim was to explore statin prescribing patterns in a longitudinal cohort of individuals with life-limiting illness, and to evaluate differences in these patterns based on secondary versus primary prevention of cardiovascular disease. DESIGN AND SETTING This study was a retrospective cohort analysis of 539 persons in an integrated, not-for-profit health maintenance organization (HMO) setting who were receiving statins at diagnosis of a cancer with 0% to 25% predicted 5-year survival. Of the cohort patients, 343 were taking statins for secondary prevention and 196 for primary prevention of cardiovascular disease. Measurements included number and timing of statin refills between diagnosis and date of death, disenrollment, or the end of the observation period. RESULTS Four hundred and ninety-six cohort members died within the observation period. Fifty-eight percent of the secondary prevention and 62% of the primary prevention group had at least one statin refill after diagnosis. There were no significant differences between groups for number of days between diagnosis and last refill, or between last refill and death. Two deaths were attributable to cardiovascular causes in each group. CONCLUSIONS Our retrospective cohort analysis of persons with incident poor-prognosis cancer describes diminished, but persistent statin refills after diagnosis. Neither timing of statin discontinuation nor cardiovascular mortality differed by prescribing indication. There may be an opportunity to reevaluate medication burden in persons taking statins for primary prevention, and it is unclear whether continuing statins prescribed for secondary prevention affects cardiovascular outcomes.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO 80231, USA.
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Abstract
CONTEXT To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. OBJECTIVE To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011. STUDY SELECTION We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality. DATA EXTRACTION For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. RESULTS We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the index's development. CONCLUSION We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.
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Affiliation(s)
- Lindsey C. Yourman
- University of California, San Francisco, Department of Medicine, Division of Geriatrics, San Francisco, CA
| | - Sei J. Lee
- University of California, San Francisco, Department of Medicine, Division of Geriatrics, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Mara A. Schonberg
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of General Medicine and Primary Care, Boston, MA
| | - Eric W. Widera
- University of California, San Francisco, Department of Medicine, Division of Geriatrics, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Alexander K. Smith
- University of California, San Francisco, Department of Medicine, Division of Geriatrics, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Stavrou EP, Buckley N, Olivier J, Pearson SA. Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? An observational cohort study using data linkage. BMJ Open 2012; 2:bmjopen-2012-000880. [PMID: 22614172 PMCID: PMC3358623 DOI: 10.1136/bmjopen-2012-000880] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE The aim was to examine statin discontinuation rates in a cohort of elderly Australians with newly diagnosed cancer using population-based secondary health data. DESIGN Observational cohort study. SETTING New South Wales, the largest jurisdiction in Australia. The Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Schemes are national programmes subsidising prescription drugs to the Australian population and Australian Government Department of Veterans' Affairs clients. PARTICIPANTS The cohort comprised 1731 cancer patients aged ≥65 years with evidence of statin use in the 90 days prior to diagnosis. They were matched to 3462 non-cancer patients prescribed statins in the same period. MAIN OUTCOME MEASURE The authors compared statin discontinuation rates up to 4 years post-diagnosis and examined the factors associated with statin discontinuation. RESULTS The proportion of cancer patients discontinuing statin therapy at 4 years (27%) was comparable to the comparison cohort; however, significantly higher proportions of the cancer cohort discontinued statins than the comparison cohort at 3, 6 and 12 months of follow-up (9.7% vs 7.4% at 12 months, respectively). More than 30% of cancer patients who died were dispensed statins within 30 days of death. Discontinuation of statin therapy in cancer patients was associated with regionalised and distant disease spread at diagnosis (p<0.001), older age (p=0.006), upper gastrointestinal organs and liver cancer (aHR 2.95, 95% CI 1.92 to 4.53) and cancer of the lung, bronchus and trachea (aHR 1.99, 95% CI 1.32 to 3.00) and poorer survival. CONCLUSIONS Medications should be rationalised at the time of a cancer diagnosis, especially in the setting of a poor prognosis. At least for some patients in our cohort, statin therapy may be inappropriately continued which adds unnecessarily to therapeutic burden.
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Affiliation(s)
- Efty P Stavrou
- Adult Cancer Program, Prince of Wales Clinical School, Lowy Cancer Research Centre, University of New South Wales, Sydney, Australia
| | - Nicholas Buckley
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Jake Olivier
- Adult Cancer Program, Prince of Wales Clinical School, Lowy Cancer Research Centre, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Adult Cancer Program, Prince of Wales Clinical School, Lowy Cancer Research Centre, University of New South Wales, Sydney, Australia
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Abernethy AP, Aziz NM, Basch E, Bull J, Cleeland CS, Currow DC, Fairclough D, Hanson L, Hauser J, Ko D, Lloyd L, Morrison RS, Otis-Green S, Pantilat S, Portenoy RK, Ritchie C, Rocker G, Wheeler JL, Zafar SY, Kutner JS. A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group. J Palliat Med 2010; 13:1407-13. [PMID: 21105763 PMCID: PMC3876423 DOI: 10.1089/jpm.2010.0261] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2010] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping. METHODS A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care. RESULTS The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success.
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Affiliation(s)
- Amy P Abernethy
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Parsons C, Hughes CM, Passmore AP, Lapane KL. Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying? Drugs Aging 2010; 27:435-49. [PMID: 20524704 DOI: 10.2165/11536760-000000000-00000] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Recent years have seen a growing recognition that dementia is a terminal illness and that patients with advanced dementia nearing the end of life do not currently receive adequate palliative care. However, research into palliative care for these patients has thus far been limited. Furthermore, there has been little discussion in the literature regarding medication use in patients with advanced dementia who are nearing the end of life, and discontinuation of medication has not been well studied despite its potential to reduce the burden on the patient and to improve quality of life. There is limited, and sometimes contradictory, evidence available in the literature to guide evidence-based discontinuation of drugs such as acetylcholinesterase inhibitors, antipsychotic agents, HMG-CoA reductase inhibitors (statins), antibacterials, antihypertensives, antihyperglycaemic drugs and anticoagulants. Furthermore, end-of-life care of patients with advanced dementia may be complicated by difficulties in accurately estimating life expectancy, ethical considerations regarding withholding or withdrawing treatment, and the wishes of the patient and/or their family. Significant research must be undertaken in the area of medication discontinuation in patients with advanced dementia nearing the end of life to determine how physicians currently decide whether medications should be discontinued, and also to develop the evidence base and provide guidance on systematic medication discontinuation.
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Affiliation(s)
- Carole Parsons
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland.
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Use of unnecessary medications by patients with advanced cancer: cross-sectional survey. Support Care Cancer 2010; 19:1313-8. [DOI: 10.1007/s00520-010-0947-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 07/01/2010] [Indexed: 10/19/2022]
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Abstract
A relatively low percentage of eligible heart disease patients receive hospice care in the United States. In 2005, the most recent year with complete reporting, only 18.36% of patients who were dying of heart failure and were hospice eligible actually received hospice care. Reasons for this include the lack of reliable prognostic indicators, the lack of a consensus on when to stop life prolonging therapies, and the relatively high cost of life-prolonging (versus life-enhancing) pharmacotherapy such as dobutamine. In addition, most studies and case reports that address symptom management in hospice care focus on cancer patients, not those with nononcologic diagnoses. This lack of evidence may discourage practitioners who care for cardiac patients from referral to hospice programs, and may keep some hospice practitioners from aggressively targeting this population. Strategies to increase hospice program utilization by heart disease patients are discussed.
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Affiliation(s)
- Joni I Berry
- ExcelleRx 1601 Cherry Street, Philadelphia, PA 19102, USA.
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Bushnell CD, Colón-Emeric CS. Secondary stroke prevention strategies for the oldest patients: possibilities and challenges. Drugs Aging 2009; 26:209-30. [PMID: 19358617 DOI: 10.2165/00002512-200926030-00003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Older adults are not only at higher risk of experiencing stroke, but also have multiple co-morbidities that make treatment for secondary stroke prevention challenging. Very few clinical trials specifically related to secondary stroke prevention treatment efficacy have focused on the oldest-old (>or=85 years) and, therefore, evidence-based recommendations for treatment specific to this population are not available. Some of the special considerations for stroke prevention treatments in older patients include careful titration of blood-pressure-lowering drugs to avoid hypotension, the risk of haemorrhagic stroke with HMG-CoA reductase inhibitors (statins) and weighing the risk of recurrent ischaemia versus bleeding in patients taking antiplatelet or anticoagulant therapy. The risk of peri-procedural complications appears to be high with both carotid angioplasty and stenting and carotid endarterectomy in older patients with carotid stenosis. Other common issues in older patients include adverse drug events, recognizing the risk of dementia, depression and osteoporosis and deciding when to discontinue secondary stroke prevention. In this review, we provide the practitioner with the evidence related to specific approaches to secondary stroke prevention in older patients, and identify the knowledge gaps that currently limit our ability to appropriately treat this vulnerable population.
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Affiliation(s)
- Cheryl D Bushnell
- Department of Neurology, Wake Forest University Health Sciences, Winston-Salem, North Carolina 27157, USA.
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Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer 2008; 17:745-8. [PMID: 19030900 DOI: 10.1007/s00520-008-0541-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/07/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cancer patients usually take many medications. The proportion of patients with advanced cancer who are taking futile drugs is unknown. MATERIALS AND METHODS We retrospectively reviewed the charts of all consecutive ambulatory patients with advanced cancer and who were receiving supportive care exclusively at palliative care clinics, Princess Margaret Hospital, to gather information on futile medications used by them. Futile medications were defined as unnecessary (when no short-term benefit to patients with respect to survival, quality of life, or symptom control was anticipated) or duplicate (two or more drugs from the same pharmacological class). Summary statistics were used to describe the results. RESULTS From November 2005 to July 2006, 82 (22%) of 372 patients were taking at least one futile medication before consultation; after initial consultation, this proportion dropped to 20% (78): 70 patients were taking unnecessary medications, while eight were on duplicate medications. The most frequent unnecessary medications used by patients were statins (56%). The most common duplicate medication involved the use of two different benzodiazepines (seven patients). CONCLUSION About one fifth of cancer outpatients at the end of life take futile medications, most commonly statins. Prospective and population-based studies are warranted to further evaluate the magnitude and consequences of futile medication use in oncology.
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Affiliation(s)
- Rachel P Riechelmann
- Department of Internal Medicine, Federal University of Sao Paulo, R: Luisiania 255, Apt 11, São Paulo, SP 04560-020, Brazil.
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Silveira MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med 2008; 11:685-93. [PMID: 18588398 DOI: 10.1089/jpm.2007.0215] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Some have advocated discontinuing statins in patients with life-limiting conditions. However, the extent of statin use at the end of life has yet to be described and whether statin prescribing may already be influenced by the presence of a recognizable, life-limiting condition is unknown. OBJECTIVE To measure the prevalence of statin use during the last 6 months of life and determine if statin prescribing varies according to the presence of a recognizable, life-limiting condition. DESIGN Matched, case-control trial nested within a retrospective, cohort study. SETTING/SUBJECTS From 3031 VISN 11 patients who died in FY2004, we identified 1584 (52%) receiving statins at least 6 months before death. Of those, we identified 337 cases with a recognizable, life-limiting condition and 1247 controls matched on number of comorbidities, age, and socioeconomic status. ANALYSES We used survival analysis to test the relationship between days without statins and the presence of a life limiting condition, while controlling for pills supplied and comorbidity score. RESULTS There was no significant difference in the time off statins between cases and controls even though the study was sufficiently powered to detect one. CONCLUSIONS These findings underscore a missed opportunity to reduce the therapeutic burden upon dying patients and limit health care spending.
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Affiliation(s)
- Maria J Silveira
- Veterans Health Administration, Health Services Research and Development Center of Excellence, Ann Arbor, Michigan, USA.
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Currow D, Abernethy AP. A framework for managing comorbid conditions in palliative care. J Palliat Med 2006; 9:620; authors reply 621-2. [PMID: 16752963 DOI: 10.1089/jpm.2006.9.620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vollrath AM, Sinclair C, Hallenbeck J. Lipid-Lowering Agents: The Authors' Response. J Palliat Med 2006. [DOI: 10.1089/jpm.2006.9.621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Annette M. Vollrath
- San Diego Hospice and Palliative Care, 4311 Third Avenue, San Diego, CA 92103
| | | | - James Hallenbeck
- VA Palo Alto Health Care System, Stanford University School of Medicine
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