1
|
Kraut RY, Youngson E, Sadowski CA, Bakal JA, Faulder D, Korownyk CS, Vucenovic A, Eurich DT, Manca DP, Lundby C, Kivi P, Manville M, Garrison SR. Antihypertensive deprescribing in frail long-term care residents (OptimizeBP): protocol for a prospective, randomised, open-label pragmatic trial. BMJ Open 2024; 14:e084619. [PMID: 39209778 PMCID: PMC11404250 DOI: 10.1136/bmjopen-2024-084619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Although antihypertensive medication use is common among frail older adults, observational studies in this population suggest blood pressure (BP) lowering may convey limited benefit and perhaps even harm. This protocol describes an antihypertensive deprescribing trial in frail older adults powered for mortality and morbidity outcomes. METHODS AND ANALYSIS Design: Prospective, parallel, randomised, open-label pragmatic trial.Participants: Long-term care (LTC) residents ≥70 years of age, diagnosed with hypertension, with mean systolic BP <135 mm Hg, ≥1 daily antihypertensive medication and no history of congestive heart failure.Setting: 18 LTC facilities in Alberta, Canada, with eligible residents identified using electronic health services data.Intervention: All non-opted-out eligible residents are randomised centrally by a provincial health data steward to either usual care, or continually reducing antihypertensives provided an upper systolic threshold of 145 mm Hg is not exceeded. Deprescribing is carried out by pharmacists/nurse practitioners, using an investigator-developed algorithm.Follow-up: Provincial healthcare databases tracking hospital, continuing care and community medical services.Primary outcome: All-cause mortality.Secondary outcome: Composite of all-cause mortality or all-cause unplanned hospitalisation/emergency department visit.Tertiary outcomes: All-cause unplanned hospitalisation/emergency department visit, non-vertebral fracture, renal insufficiency and cost of care. Also, as assessed roughly 135-days postrandomisation, fall in the last 30 days, worsening cognition, worsening activities of daily living and skin ulceration.Process outcomes: Number of daily antihypertensive medications (broken down by antihypertensive class) and average systolic and diastolic BP over study duration.Primary outcome analysis: Cox proportional hazards survival analysis.Sample size: The trial will continue until observation of 247 primary outcome events has occurred.Current status: Enrolment is ongoing with ~400 randomisations to date (70% female, mean age 86 years). ETHICS AND DISSEMINATION Ethics approval was obtained from the University of Alberta Health Ethics Review Board (Pro00097312) and results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05047731.
Collapse
Affiliation(s)
- Roni Y Kraut
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Douglas Faulder
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Christina S Korownyk
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta, Edmonton, Alberta, Canada
| | - Ana Vucenovic
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta, Edmonton, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Donna P Manca
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Paul Kivi
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Margaret Manville
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- Island Health, Victoria, British Columbia, Canada
| | - Scott R Garrison
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
Hung A, Wilson LE, Smith VA, Pavon JM, Sloan CE, Hastings SN, Maciejewski ML. Impact of comprehensive medication reviews on potentially inappropriate medication discontinuation in Medicare beneficiaries. J Am Geriatr Soc 2024; 72:2347-2358. [PMID: 38826070 PMCID: PMC11323205 DOI: 10.1111/jgs.19013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/12/2024] [Accepted: 05/04/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The use of potentially inappropriate medications (PIMs) is associated with increased risk of hospitalizations and emergency room visits and varies by racial and ethnic subgroups. Medicare's nationwide medication therapy management (MTM) program requires that Part D plans offer an annual comprehensive medication review (CMR) to all beneficiaries who qualify, and provides a platform to reduce PIM use. The objective of this study was to assess the impact of CMR on PIM discontinuation in Medicare beneficiaries and whether this differed by race or ethnicity. METHODS Retrospective cohort study of community-dwelling Medicare Part D beneficiaries ≥66 years of age who were eligible for MTM from 2013 to 2019 based on 5% Medicare fee-for-service claims data linked to the 100% MTM data file. Among those using a PIM, MTM-eligible CMR recipients were matched to non-recipients via sequential stratification. The probability of PIM discontinuation was estimated using regression models that pooled yearly subcohorts accounting for within-beneficiary correlations. The most common PIMs that were discontinued after CMR were reported. RESULTS We matched 24,368 CMR recipients to 24,368 CMR non-recipients during the observation period. Median age was 74-75, 35% were males, most were White beneficiaries (86%-87%), and the median number of PIMs was 1. In adjusted analyses, CMR receipt was positively associated with PIM discontinuation (adjusted relative risk [aRR]: 1.26, 95% CI: 1.20-1.32). There was no evidence of differential impact of CMR by race or ethnicity. The PIMs most commonly discontinued after CMR were glimepiride, zolpidem, digoxin, amitriptyline, and nitrofurantoin. CONCLUSIONS Among Medicare beneficiaries who are using a PIM, CMR receipt was associated with PIM discontinuation, suggesting that greater CMR use could facilitate PIM reduction for all racial and ethnic groups.
Collapse
Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke-Margolis Center for Health Policy, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Valerie A. Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Juliessa M. Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
| | - Caroline E. Sloan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke-Margolis Center for Health Policy, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Susan N. Hastings
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
| | - Matthew L. Maciejewski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke-Margolis Center for Health Policy, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| |
Collapse
|
3
|
Hung A, Kim YH, Pavon JM. Deprescribing in older adults with polypharmacy. BMJ 2024; 385:e074892. [PMID: 38719530 DOI: 10.1136/bmj-2023-074892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.
Collapse
Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Co-first authors
| | - Yoon Hie Kim
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Co-first authors
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center (GRECC) Durham VA Health Care System, Durham, NC, USA
| |
Collapse
|
4
|
McDonald EG, Lundby C, Thompson W, Boyd C, Farrell B, Gagnon C, Herbin J, Khuong N, Moriarty F, Pierson T, Scott S, Scott IA, Silvius J, Spinewine A, Steinman MA, Tannenbaum C, Trimble J, Turner JP, Reeve E. Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks. Expert Rev Clin Pharmacol 2024; 17:433-440. [PMID: 38739460 DOI: 10.1080/17512433.2024.2355270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.
Collapse
Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology in the School of Medicine, the Center on Aging and Health, and the departments of Epidemiology and Health Policy and Management at Johns Hopkins University in Baltimore, Baltimore, MD, USA
| | - Barbara Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Jennie Herbin
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tiphaine Pierson
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian A Scott
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jim Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Provincial Seniors Health & Continuing Care, Alberta Health Services, Alberta, Canada
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group UCLouvain, Brussels, Belgium
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Cara Tannenbaum
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Johanna Trimble
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Melbourne, SA, Australia
| |
Collapse
|
5
|
Pajewski NM, Cohen JB. ATEMPTing to navigate between "lower is better" and "less is more". THE LANCET. HEALTHY LONGEVITY 2024; 5:e164-e165. [PMID: 38342122 DOI: 10.1016/s2666-7568(24)00024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024] Open
Affiliation(s)
- Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, PA, USA
| |
Collapse
|
6
|
Lundby C, Thompson W. Advancing deprescribing: Learnings from the first international conference on deprescribing. Basic Clin Pharmacol Toxicol 2024; 134:3-5. [PMID: 37984365 DOI: 10.1111/bcpt.13963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Carina Lundby
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Wade Thompson
- Department of Anaesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| |
Collapse
|