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Frisk G, Szilcz M, Hedman C, Björkhem-Bergman L. Treatment with Antithrombotics in the Last Year of Life-Incidence of Bleeding and Side Effects After Deprescribing. J Palliat Med 2024. [PMID: 38973710 DOI: 10.1089/jpm.2024.0108] [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: 07/09/2024] Open
Abstract
Background: Patients in palliative care are often treated with antithrombotics, even in the late stages of disease. Clear guidelines regarding deprescribing are lacking. Objective: The aims of this study were to investigate bleeding as a side effect of antithrombotic treatments the last year in life and map the timing of deprescribing. Methods: A retrospective cohort study was performed. All medical records were screened for deceased patients admitted to a palliative care unit in Stockholm, Sweden, over a 3-year period. Patients with antithrombotics were identified; data on bleeding, and on side effects due to deprescribing, were extracted from the medical records. Log-binomial models were used to explore factors associated with bleeding. Results: Of 1501 patients, 897 were treated with antithrombotics during the last year of life (mean age 75 years, 41% women). Of these, 56% continued treatment up until the last 3 days of life. Of the 897 patients, 144 (16%) had at least one bleeding during the treatment. The risk for bleeding was significantly higher for men with prostate cancer compared to other cancer forms, adjusted relative risk 1.9 (95% CI 1.1-3.2). No difference in risk for bleeding was found between sex, age groups, type of antithrombotics, or indication. Two patients (0.2%) developed strokes after antithrombotics were deprescribed. Conclusions: Treatment with antithrombotics during the last year of life is associated with a high risk of bleeding. In this cohort, men with prostate cancer seemed to have more side effects of bleeding than other groups. Few experienced side effects from deprescribing.
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Affiliation(s)
- Gabriella Frisk
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
| | - Máté Szilcz
- Department of Medical Epidemiology and Biostatistics, C8 Medicinsk epidemiologi och biostatistik, MEB Jonell, Karolinska Institutet, Stockholm, Sweden
| | - Christel Hedman
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinician Sciences Lund, Lund University, Lund, Sweden
| | - Linda Björkhem-Bergman
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
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2
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Huisman BAA, Geijteman ECT, Dees MK, van Zuylen L, van der Heide A, Perez RSGM. Better drug use in advanced disease: an international Delphi study. BMJ Support Palliat Care 2023; 13:e115-e121. [PMID: 30446489 PMCID: PMC10646859 DOI: 10.1136/bmjspcare-2018-001623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 11/03/2022]
Abstract
Patients with a limited life expectancy use many medications, some of which may be questionable. OBJECTIVES : To identify possible solutions for difficulties concerning medication management and formulate recommendations to improve medication management at the end of life. METHODS : A two-round Delphi study with experts in the field of medication management and end-of-life care (based on ranking in the citation index in Web of Science and relevant publications). We developed a questionnaire with 58 possible solutions for problems regarding medication management at the end of life that were identified in previously performed studies. RESULTS : A total of 42 experts from 13 countries participated. Response rate in the first round was 93%, mean agreement between experts for all solutions was 87 % (range 62%-100%); additional suggestions were given by 51%. The response rate in the second round was 74%. Awareness, education and timely communication about medication management came forward as top priorities for guidelines. In addition, solutions considered crucial by many of the experts were development of a list of inappropriate medications at the end of life and incorporation of recommendations for end-of-life medication management in disease-specific guidelines. CONCLUSIONS : In this international Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care. These findings may contribute to the development of clinical practice guidelines for medication management in end-of-life care.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne K Dees
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
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Shrestha S, Poudel A, Cardona M, Steadman KJ, Nissen LM. Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis. Ther Adv Drug Saf 2021; 12:20420986211052343. [PMID: 34707802 PMCID: PMC8543710 DOI: 10.1177/20420986211052343] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: The decision to deprescribe medications used for both disease prevention and
symptom control (dual-purpose medications or DPMs) is often challenging for
clinicians. We aim to establish the impact of deprescribing DPMs on
patient-related outcomes for older adults near end-of-life (EOL). Methods: This systematic review was conducted according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guideline.
Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google
Scholar until December 2019 for studies on deprescribing intervention with a
control group (with or without randomisation); targeting ⩾65-year olds, at
EOL, with at least one life-limiting illness and at least one potentially
inappropriate DPM. We were interested in any patient-related outcomes.
Studies with similar outcome assessment criteria were subjected to
meta-analysis and narrative synthesis otherwise. The risk of bias was
assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised
controlled trials (RCTs) and quasi-experimental non-randomised controlled
studies, respectively. Results: Five studies covering 689 participants with mean age 81.6–85.7 years, the
majority (74.6–100%) with dementia were included. The risk of bias was
moderate to low. The deprescribing of DPMs lowered the risk of mortality
(risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and
referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did
not have a significant impact on the risk of falls, non-vertebral fracture,
emergency presentation, unplanned hospital admission, or general
practitioner visits. No significant difference was observed in the quality
of life, physical and cognitive functions between the intervention and
control groups. Conclusion: There is some evidence that deprescribing of DPMs for older adults near the
EOL can lower the risk of mortality and referral to acute care facilities,
but there are insufficient good-quality studies powered to confirm a benefit
in terms of quality of life, physical or cognitive function, health service
utilisation and adverse events. Plain Language Summary What is the health impact of withdrawal or dose reduction of
medication used for disease prevention and symptom control in older
adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced
diseases such as cancer, dementia, and organ failure tend to have a limited
life expectancy. With the progression of these diseases towards the
end-of-life, the intensity for day-to-day supportive care becomes
increasingly necessary. The use of medications for symptom management is a
critical part of such care, but the use of medications for long-term disease
prevention can become irrelevant due to the already shortened life
expectancy and may become harmful due to alterations in physiology and
pharmacology associated with age and frailty. This necessitates the
withdrawal or dose reduction of inappropriate medications, the process
called deprescribing. The decision to deprescribe medications used for both
disease prevention and symptom control (DPMs) in this population is often
challenging for clinicians. In this context, whether deprescribing of DPMs
can improve patient-related health outcomes is unknown. Methods: Evidence from the literature was reviewed and analysed,
and the quality of studies was assessed. Five studies were identified, which
had 689 participants with an average age above 80 years and mostly suffering
from dementia. Results: The analysis of these studies showed deprescribing of
DPMs lowered the risk of death and referral to acute care facilities at 12
months but had no significant impact on falls, non-vertebral fractures,
emergency presentations, unplanned hospital admission, general practitioner
visits, quality of life, physical and mental functions. Conclusion: In conclusion, there were insufficient numbers of
high-quality studies powered to confirm whether deprescribing of DPMs
reduces adverse events, health service use, or improves the quality of life
or functioning in older adults near the end of life.
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Affiliation(s)
- Shakti Shrestha
- School of Pharmacy, The University of Queensland, Pharmacy Australia Centre of Excellence, Level 4, 20 Cornwall Street, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Magnolia Cardona
- EBP Professorial Unit, Gold Coast University Hospital, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Kathryn J Steadman
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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Huisman BAA, Geijteman ECT, Arevalo JJ, Dees MK, van Zuylen L, Szadek KM, van der Heide A, Steegers MAH. Use of antithrombotics at the end of life: an in-depth chart review study. BMC Palliat Care 2021; 20:110. [PMID: 34271885 PMCID: PMC8285840 DOI: 10.1186/s12904-021-00786-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00786-3.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Hospice Kuria, Amsterdam, The Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jimmy J Arevalo
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Marianne K Dees
- Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Anfinogenova ND, Trubacheva IA, Popov SV, Efimova EV, Ussov WY. Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases. Expert Opin Drug Saf 2021; 20:1191-1206. [PMID: 33970732 DOI: 10.1080/14740338.2021.1928632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.
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Affiliation(s)
- Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Irina A Trubacheva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Elena V Efimova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Wladimir Y Ussov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
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Jaramillo-Hidalgo J, Lozano-Montoya I, Tornero-Torres O, Tejada-González P, Fuentes-Irigoyen R, Gómez-Pavón FJ. Prevalence of potentially inappropriate prescription in community-dwelling patients with advanced dementia and palliative care needs. Rev Esp Geriatr Gerontol 2021; 56:203-207. [PMID: 34001344 DOI: 10.1016/j.regg.2021.03.001] [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: 11/30/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To establish the prevalence of potentially inappropriate prescription (PIP) in older people with advanced dementia, monitored by a Geriatric Home Care Unit (GHC), as well as the associated risk factors and costs. METHODS Community-dwelling patients ≥65 years with an advanced dementia diagnosis (GDS-FAST≥7a) and poor 1-year vital prognosis (Frail-VIG≥0.6) were included. Pharmacotherapy history was reviewed retrospectively, collecting functional and cognitive status, on the first GHC visit, of patients assessed January 2016-January 2019. Potentially inappropriate medication was defined following STOPP-Frail criteria. RESULTS 100 patients included (76% women, 89.15±5.8 years). Total medications prescribed 760 (7.63±3.4 drugs per patient). 85% patients were given at least one drug considered to be PIP. 26% (196) of the total drugs registered were PIPs. Patients who were prescribed an inappropriate drug showed a higher number of total prescribed drugs (7.92±3.42 vs 6.00±2.24; p 0.04) and a higher frequency of polypharmacy (84.7% vs 60%; p 0.025). Risk of receiving inappropriate medication increased by 24% for each additional drug prescribed (OR 1.24; 95% CI 1.01-1.52; p 0.04). The costs associated with PIP were 113.99 euros per 100 patients/day; 41,606.35 euros per 100 patients/year. CONCLUSIONS Prescription of PIP to community-dwelling patients with severe dementia and poor vital prognosis is common and is associated with high economic impact in this population group.
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Affiliation(s)
- Javier Jaramillo-Hidalgo
- Servicio de Geriatría, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain; Facultad de Medicina, Universidad Alfonso X el Sabio, Av de la Universidad, 1, 28691- Villanueva de la Cañada, Madrid, Spain.
| | - Isabel Lozano-Montoya
- Servicio de Geriatría, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain; Facultad de Medicina, Universidad Alfonso X el Sabio, Av de la Universidad, 1, 28691- Villanueva de la Cañada, Madrid, Spain
| | - Olga Tornero-Torres
- Servicio de Farmacia, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain
| | - Pilar Tejada-González
- Servicio de Farmacia, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain
| | - Raquel Fuentes-Irigoyen
- Servicio de Farmacia, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain
| | - Francisco J Gómez-Pavón
- Servicio de Geriatría, Hospital Central de la Cruz Roja San José y Santa Adela, Av/Reina Victoria, 24, 28003 Madrid, Spain; Facultad de Medicina, Universidad Alfonso X el Sabio, Av de la Universidad, 1, 28691- Villanueva de la Cañada, Madrid, Spain
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Duncan I, Maxwell TL, Huynh N, Todd M. Polypharmacy, Medication Possession, and Deprescribing of Potentially Non-Beneficial Drugs in Hospice Patients. Am J Hosp Palliat Care 2020; 37:1076-1085. [PMID: 32662276 DOI: 10.1177/1049909120939091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients frequently have comorbidities that when combined with their primary diagnosis qualifies the patient for hospice. Consequently, patients are at risk for polypharmacy due to the number of medications prescribed to treat both the underlying conditions and the related symptoms. Polypharmacy is associated with negative consequences, including increased risk for adverse drug events, drug-drug and drug-disease interactions, reduced functional status and falls, multiple geriatric syndromes, medication nonadherence, and increased mortality. Polypharmacy also increases the complexity of medication management for caregivers and contributes to the cost of prescription drugs for hospices and patients. Deprescribing or removing nonbeneficial or ineffective medications can reduce polypharmacy in hospice. We study medication possession ratios and rates of deprescribing of commonly prescribed but potentially nonbeneficial classes of medication using a large hospice pharmacy database. Prevalence of some classes of potentially inappropriate medications is high. We report possession ratios for 10 frequently prescribed classes, and, because death and prescription termination are competing events, we calculate prescription termination rates using Cumulative Incidence Functions. Median duration of antifungal and antiviral medications is brief (5 and 7 days, respectively), while statins and diabetes medications have slow discontinuance rates (median termination durations of 93 and 197 days). Almost all patients with a proton pump inhibitor prescription have the drug for their entire hospice stay. Data from this study identify those drug classes that are commonly deprescribed slowly, suggesting drug classes and diagnoses that hospices may wish to focus on more closely, as they act to limit polypharmacy and reduce prescription costs.
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Affiliation(s)
- Ian Duncan
- Department of Statistics & Applied Probability, 8786University of California-Santa Barbara, CA, USA
| | | | - Nhan Huynh
- Department of Statistics & Applied Probability, 8786University of California-Santa Barbara, CA, USA
| | - Marisa Todd
- 142913Enclara Pharmacia Inc, Philadelphia, PA, USA
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8
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Lundby C, Jensen J, Larsen SP, Hoffmann H, Pottegård A, Reilev M. Use of medication among nursing home residents: a Danish drug utilisation study. Age Ageing 2020; 49:814-820. [PMID: 32147721 DOI: 10.1093/ageing/afaa029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Data on drug utilisation patterns in nursing home populations is scarce. We aimed to describe drug use patterns in Danish nursing home residents. METHODS We established a cohort of 5,179 individuals (63% women; median age of 84 years) admitted into 94 nursing homes across Denmark during 2015-2017. Data on prescription drug use and other census data were obtained from the nationwide Danish health registries. RESULTS The total number of drug classes filled increased from a median of 6 drugs (interquartile range [IQR] 3-9) at 18-24 months before nursing home admission to a median of 8 drugs (IQR 6-11) just after admission, with the most common drug classes comprising paracetamol (61%), platelet inhibitors (41%), proton pump inhibitors (34%), statins (33%) and potassium supplements (31%). The incidence rate of new drug treatments increased from 21 new treatments/100 residents/month at 12-24 months before admission to a peak of 71 new treatments/100 residents/month in the month prior to admission, while it levelled off to about 34 new treatments/100 residents/month after 6-9 months. The drug classes primarily responsible for this peak were laxatives, antibiotics and analgesics. The largest absolute increases were seen for laxatives (53%), paracetamol (43%) and antidepressants (36%), all showing a marked increase up to and following admission. A high proportion of residents remained on therapy in the 3-year period following admission, with users of antidepressants and antidementia drugs being most persistent. CONCLUSION Nursing home admission is associated with an increase in use of both predominantly preventive and non-preventive drug classes.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | | | | | | | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
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9
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Aitken C, Boyd M, Nielsen L, Collier A. Medication use in aged care residents in the last year of life: A scoping review. Palliat Med 2020; 34:832-850. [PMID: 32286162 DOI: 10.1177/0269216320911596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life. AIM The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision. DESIGN A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018. DATA SOURCES We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life. RESULTS A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications. CONCLUSION Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.
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Affiliation(s)
| | - Michal Boyd
- The University of Auckland, Auckland, New Zealand
| | | | - Aileen Collier
- The University of Auckland, Auckland, New Zealand.,Flinders University, Adelaide, SA, Australia.,University of Tasmania, Hobart, TAS, Australia
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10
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Vinkeroye C, Deliens L, Christiaens T, Dilles T. Balancing medication use in nursing home residents with life-limiting disease. Eur J Clin Pharmacol 2019; 75:969-977. [DOI: 10.1007/s00228-019-02649-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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12
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STOPPFrail (Screening Tool of Older Persons’ Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care. Eur J Clin Pharmacol 2019; 75:723-731. [DOI: 10.1007/s00228-019-02630-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/10/2019] [Indexed: 11/28/2022]
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13
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Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, Christiaens T. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37-48. [PMID: 30229704 DOI: 10.1177/0269216318801124] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. DESIGN: Systematic review, registered in PROSPERO (CRD42017073693). DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
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Affiliation(s)
- Kristel Paque
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Dilles
- 3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.,4 Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,5 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Tait PA, Pirone C, To THM. Providing high‐quality pharmaceutical care for the dying older person in hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paul A. Tait
- Southern Adelaide Palliative Services Division of Rehabilitation, Aged Care and Palliative Care Flinders Medical Centre Adelaide Australia
- Discipline of Palliative and Supportive Services College of Nursing and Health Sciences Flinders University Adelaide Australia
| | - Christy Pirone
- Clinical Governance Unit Flinders Medical Centre Adelaide Australia
| | - Timothy Hong Man To
- Southern Adelaide Palliative Services Division of Rehabilitation, Aged Care and Palliative Care Flinders Medical Centre Adelaide Australia
- Discipline of Palliative and Supportive Services College of Nursing and Health Sciences Flinders University Adelaide Australia
- Faculty of Health University of Technology Sydney Australia
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15
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van der Meer HG, Taxis K, Pont LG. Changes in Prescribing Symptomatic and Preventive Medications in the Last Year of Life in Older Nursing Home Residents. Front Pharmacol 2018; 8:990. [PMID: 29410623 PMCID: PMC5787351 DOI: 10.3389/fphar.2017.00990] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background: At the end of life goals of care change from disease prevention to symptomatic control, however, little is known about the patterns of medication prescribing at this stage. Objectives: To explore changes in prescribing of symptomatic and preventive medication in the last year of life in older nursing home residents. Methods: A retrospective cohort study was conducted using pharmacy medication supply data of 553 residents from 16 nursing home facilities around Sydney, Australia. Residents received 24-h nursing care, were aged ≥ 65 years, died between June 2008 and June 2010 and were using at least one medication 1 year before death. Medications were classified as symptomatic, preventive, or other. A linear mixed model was used to compare changes in prescribing in the last year of life. Results: 68.1% of residents were female, mean age was 88.0 (SD: 7.5) years and residents used a mean of 9.1 (SD: 4.1) medications 1 year before death. The mean number of symptomatic medications per resident increased from 4.6 medications 1 year before death to 5.1 medications at death [95% CI 4.4–4.7 to 5.9–5.2, P = 0.000], while preventive medication decreased from 2.0 to 1.4 medications [95% CI 1.9–2.1 to 1.3–1.5, P = 0.000]. Symptomatic medications were used longer in the last year of life, compared to preventive medications (336.3 days [95% CI 331.8–340.8] versus 310.9 days [95% CI 305.2–316.7], P = 0.000). Conclusion: Use of medications for symptom relief increased throughout the last year of life, while medications for prevention of long-term complications decreased. But changes were slight and clinical relevance can be questioned.
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Affiliation(s)
- Helene G van der Meer
- Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Lisa G Pont
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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16
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Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians. Eur J Clin Pharmacol 2017; 74:331-338. [DOI: 10.1007/s00228-017-2376-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/12/2017] [Indexed: 01/25/2023]
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17
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Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study. Am J Med 2017; 130:927-936.e9. [PMID: 28454668 DOI: 10.1016/j.amjmed.2017.02.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. METHODS We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. RESULTS Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% (P <.001 for trend). Although older adults who died from cancer had the largest increase in the number of drugs (mean difference, 3.37; 95% confidence interval, 3.35 to 3.40), living in an institution was independently associated with a slower escalation (β = -0.90, 95% confidence interval, -0.92 to -0.87). During the final month before death, analgesics (60.8%), anti-throm-botic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%), and β-blocking agents (41.1%) were the 5 most commonly used drug classes. Angiotensin-converting enzyme inhibitors and statins were used by, respectively, 21.4% and 15.8% of all individuals during their final month of life. CONCLUSION Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life.
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Sevilla-Sánchez D, Molist-Brunet N, Amblàs-Novellas J, Espaulella-Panicot J, Codina-Jané C. Potentially inappropriate medication at hospital admission in patients with palliative care needs. Int J Clin Pharm 2017; 39:1018-1030. [PMID: 28744675 DOI: 10.1007/s11096-017-0518-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 07/21/2017] [Indexed: 01/23/2023]
Abstract
Background Potentially inappropriate medications (PIMs) are common in older patients with polypharmacy, and are related to negative clinical results. Little information is available on the characteristics and consequences of PIMs in patients with advanced chronic conditions and palliative care needs. Objective To evaluate, for this population: (i) the prevalence of PIMs; (ii) the possible risk factors associated with its onset; and (iii) the related clinical consequences. Setting Acute-hospital care Geriatric Unit (AGU) in County of Osona, Spain. Method Ten-month prospective cross-sectional study. Patients with palliative care needs were identified according to the NECPAL CCOMS-ICO® test. Upon hospital admission, a multidisciplinary team consisting of a pharmacist and two AGU physicians determined the PIMs of the routine chronic medication of the patients. Sociodemographic and pharmacological data were collected with the objective of determining possible risk factors related to the existence of PIMs. Main outcome measure Prevalence and type of PIMs according to STOPP version 2 and MAI criteria at the time of hospital admission. Furthermore, days of hospital admission, destination at hospital discharge and survival analysis at 12 months related to PIMs were evaluated. Results Two hundred thirty-five patients (mean age 86.80, SD 5.37; 65.50% women) were recruited. According to the STOPP criteria, 88.50% of patients had ≥1 criterion (mainly 'indication of medication', followed by those that affect the nervous system and psychotropic drugs and risk drugs in people suffering from falls), and according to the MAI tool, 97.40% of the patients had some criterion related to inappropriate medication (mainly, duration of therapy). The following conditions were identified as risk factors for the existence of PIMs: insomnia, anxiety-depressive disorder, falls, pain, excessive polypharmacy and therapeutic complexity. There were no differences among patients in days of hospital stay, discharge's destination or survival at 12 months, regardless of the tool used. Conclusion The presence of PIMs is high in patients requiring palliative care. Some potentially modifiable risk factors such as the pharmacological ones are associated with a greater presence of inappropriate medication. The presence of PIMs does not affect this population in terms of mortality.
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Affiliation(s)
- Daniel Sevilla-Sánchez
- Pharmacy Department, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain.
| | - Núria Molist-Brunet
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Jordi Amblàs-Novellas
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Joan Espaulella-Panicot
- Acute Geriatric Unit, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
- Geriatric and Palliative Care Territorial Unit, Hospital Universitari de la Santa Creu de Vic, Vic, Spain
| | - Carles Codina-Jané
- Pharmacy Department, Hospital Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Vic, Barcelona, Spain
- Pharmacy Department, Hospital Clinic de Barcelona, Vic, Barcelona, Spain
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Poudel A, Yates P, Rowett D, Nissen LM. Use of Preventive Medication in Patients With Limited Life Expectancy: A Systematic Review. J Pain Symptom Manage 2017; 53:1097-1110.e1. [PMID: 28192226 DOI: 10.1016/j.jpainsymman.2016.12.350] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/05/2016] [Accepted: 12/29/2016] [Indexed: 01/20/2023]
Abstract
CONTEXT Optimal prescribing in patients with limited life expectancy (LLE) remains unclear. OBJECTIVES This study systematically reviews the published literature regarding the use of preventive medication in patients with reduced life expectancy. METHODS A systematic literature search was conducted using three databases (MEDLINE, EMBASE, and CINAHL). Articles published in English from January 1995 to December 2015 were retrieved for analysis to identify peer-reviewed, observational studies assessing use of preventive medications in patients with LLE. Inclusion criteria were: patients with a LLE (less than or equal to two years); prescribed/used preventive medications. RESULTS Of the 15 studies meeting our eligibility criteria, six were from inpatient hospital settings, five in palliative care, three in nursing homes, and one in community settings. The most common life-limiting illnesses described in the studies were cancer (n = 6), cardiovascular diseases (n = 4), dementia and cognitive impairment (n = 2), and other life-limiting illnesses (n = 3). Lipid-lowering medications, especially the statins were frequently prescribed preventive medication followed by antiplatelets, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, anti-osteoporosis medications, and calcium channel blockers. Only four studies reported the instances of medication withdrawal. CONCLUSION Patients continue to receive medications that are not prescribed as symptomatic treatment despite having a LLE. Very few rigorous studies have been conducted on minimizing preventive medications in patients with LLE, and expert opinion varies on medication optimization at the end of life. A consensus guideline that addresses this gap is of paramount importance.
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Affiliation(s)
- Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Debra Rowett
- Repatriation General Hospital, Adelaide, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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Pont L, Jansen K, Schaufel MA, Haugen DF, Ruths S. Drug utilization and medication costs at the end of life. Expert Rev Pharmacoecon Outcomes Res 2016; 16:237-43. [PMID: 26919437 DOI: 10.1586/14737167.2016.1158106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the end stages of life, drug treatment goals shift to symptom control and quality of life and as such changes in drug utilization are expected. The aim of this paper is to review the extent to which costs are considered in drug utilization research at the end of life, with a particular focus on the outcome measures being used. This systematic review identified seven studies across varied settings studies reporting both drug utilization and medication cost outcome measures. The main factors identified that impacted medication use and cost were the time period considered and the provision of specialist palliative care services. Combining drug utilization and medication cost outcomes is critical for the allocation of healthcare resources and the development of a sound health policy.
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Affiliation(s)
- Lisa Pont
- a Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , North Ryde , Australia
| | - Kristian Jansen
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,c Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
| | - Margrete Aase Schaufel
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,d Department of Thoracic Medicine , Haukeland University Hospital , Bergen , Norway
| | - Dagny Faksvåg Haugen
- e Regional Centre of Excellence for Palliative Care, Haukeland University Hospital , Bergen , Norway.,f Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Sabine Ruths
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,c Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
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