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Li X, Zeng Z, Fan X, Wang W, Luo X, Yang J, Chang Y. Trends and Patterns of Systemic Glucocorticoid Prescription in Primary Care Institutions in Southwest China, from 2018 to 2021. Risk Manag Healthc Policy 2023; 16:2849-2868. [PMID: 38146314 PMCID: PMC10749547 DOI: 10.2147/rmhp.s436747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/02/2023] [Indexed: 12/27/2023] Open
Abstract
Purpose The purpose of this study was to investigate the prescribing patterns and usage trends of systemic glucocorticoids in primary care institutions located in Southwest China from 2018 to 2021. Materials and Methods A retrospective cross-sectional analysis of systemic glucocorticoids prescriptions was conducted in 32 primary care institutions located in Southwest China between 2018 and 2021. Prescriptions of systemic glucocorticoids were classified as appropriate or inappropriate use. Inappropriate use was further classified into (1) inappropriate indications and (2) inappropriate selection of glucocorticoids. Generalized estimation equations were employed to investigate the factors associated with inappropriate utilization of systemic glucocorticoids. The seasonal autoregressive integrated moving average (SARIMA) model was employed to predict the rate of inappropriate glucocorticoids prescriptions. Results A total of 203,846 (92.89%) prescriptions were included, both the number of systemic glucocorticoids prescriptions and inappropriate prescriptions increased in winter. Diseases of the respiratory system (68.90%) were the most frequent targets of systemic glucocorticoids use. Of all prescriptions, 73.18% exhibited inappropriate indications, while 0.05% demonstrated inappropriate selection. The utilization of systemic glucocorticoids was deemed inappropriate for diseases of the respiratory system (94.19%), followed by diseases of the digestive system (87.75%). Physicians, who were female or younger than 33 years old, possess lower levels of education and professional titles and exhibit a higher likelihood of inappropriately prescribing systemic glucocorticoids. The phenomenon of inappropriate glucocorticoids use was commoner among male patients aged 65 years and older. After conducting model verification, it was determined that the SARIMA model could be used to predict the monthly rate of inappropriate systemic glucocorticoids prescriptions in primary care institutions in southwest China. Conclusion The inappropriate use of systemic glucocorticoids remains a significant concern in primary care institutions. In this regard, continuing education and professional knowledge training of physicians should be strengthened in the future.
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Affiliation(s)
- Xiaoyi Li
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Zhen Zeng
- Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou Province, People’s Republic of China
| | - Xingying Fan
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Wenju Wang
- School of Public Health, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Xiaobo Luo
- School of Public Health, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Junli Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
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Paulamäki J, Jyrkkä J, Hyttinen V, Huhtala H, Jämsen E. Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study. Res Social Adm Pharm 2023; 19:1372-1379. [PMID: 37355437 DOI: 10.1016/j.sapharm.2023.06.005] [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: 04/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear. OBJECTIVE To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation. METHODS This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence. RESULTS Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation. CONCLUSIONS PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.
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Affiliation(s)
- Jasmin Paulamäki
- Faculty of Medicine and Health Technology, Clinical Medicine, Tampere University, FI-33014, Tampere University, Finland; Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Johanna Jyrkkä
- Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Heini Huhtala
- Faculty of Social Sciences, Health Sciences, Tampere University, FI-33014, Tampere University, Finland.
| | - Esa Jämsen
- Faculty of Medicine (Clinicum), University of Helsinki, P.O. Box 63, FI-00014, University of Helsinki, Finland; Department of Geriatrics, Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, HUS, Finland.
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Alfahmi AA, Curtain CM, Salahudeen MS. Assessment of Knowledge, Attitude and Practices of the Hospital and Community Pharmacists in Saudi Arabia (Jeddah) towards Inappropriate Medication Use in Older Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1635. [PMID: 36674385 PMCID: PMC9863709 DOI: 10.3390/ijerph20021635] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 06/17/2023]
Abstract
In Saudi Arabia, the older adult population is growing and is projected to increase three-fold by 2030. Potentially inappropriate medications (PIMs) are harmful to older adults' and have a direct impact on clinical, health and economic outcomes. Pharmacists have a vital role in medication tailoring for older adults as multidisciplinary team members. However, there is also a paucity of research regarding pharmacists' participation in detecting and avoiding PIMs use among older adults in Saudi Arabia. A cross-sectional, self-administered survey was conducted to assess the knowledge, practices, and attitude of pharmacists from seven hospitals and ten community pharmacies in Jeddah, Saudi Arabia. The survey comprised three sections; (i) identifying participants' general characteristics, (ii) assessing their knowledge of PIMs use in older adults and (iii) examining the pharmacist's attitude towards the procedures followed in dispensing for older adults. Inferential and descriptive statistics were used to analyse the survey data. A total of 157 community and hospital pharmacists participated in this study. Most of them dispensed medication weekly to older adults (85.4%), and 43.3% had relevant work experience of six to ten years. Though 44.6% of the participants were aware of PIMs that older adults should avoid, only 10.8% claimed adequate knowledge about PIMs. From the given three clinical case scenarios, a minority of pharmacists (21.7%) chose the correct answers, with a mean score of 2.38 ± 2.91 (95% CI 2.35-3.15). Participants who claimed to have knowledge of PIMs had a significantly higher mean score than those who did not, 4.59 ± 2.81 25 (95% CI 2.35-2.61). A minority of the pharmacists (14.7%) used screening tools such as STOPP, Beers criteria, or Medication Appropriateness Index (MAI) to detect PIMs in older adults. No statistically significant differences were detected when comparing the levels of knowledge of pharmacists with 1 to 5 years of practice to pharmacists with 6 to 15 and more years of experience (p = 0.431). Pharmacists' knowledge, attitude and practices toward PIMs use in older adults in Saudi Arabia should be improved. The application of PIMs detection tools such as STOPP/START or Beers criteria currently has no place in day-to-day pharmacists' roles in Saudi Arabia. Therefore, concerned stakeholders should develop educational programs to improve pharmacists' knowledge of PIMs and promote the effective use of PIM screening tools such as Beers and STOPP criteria in their practice.
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Akande-Sholabi W, Fafemi A. Beers criteria and potentially inappropriate medications in elderly: awareness, practice, knowledge and barriers among community pharmacists in Nigeria. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2022. [DOI: 10.1186/s43094-022-00451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Potential inappropriate medications (PIMs) used in the elderly are an avoidable source of disease and death. Beers Criteria is among the commonly used measures that document PIMs. Community pharmacists’ knowledge on PIMs and existing criteria are essential to moderate the use of PIMs which would enhance overall health outcomes and costs. This study investigates awareness, knowledge, practice, and barriers of PIMs among community pharmacists in Ibadan, Nigeria.
Methods
A cross-sectional study was carried out on 109 community pharmacists with the use of a self-administered questionnaire. Nine clinical vignettes based on the 2019 Beers Criteria were used to evaluate PIMs knowledge. Practice behavior regarding elderly clients was evaluated using a 5-point Likert scale with six items. Data were summarized by descriptive and inferential statistics.
Results
Respondents who knew guidelines that listed specific PIMs were (49; 47.1%), and of these, (21; 42.9%) were aware of Beers Criteria. From all the respondents, only 45 (41.3%) demonstrated good knowledge of Beers Criteria, while 82 (75.2%) narrated good practice when dealing with elderly clients in terms of asking suitable questions and contemplating their ages while dispensing medications. Major barrier identified was lack of knowledge of Beers Criteria (80; 73.4%). Pharmacists who were aware of Beers Criteria statistically had better knowledge than others (p = 0.003).
Conclusion
Beers Criteria awareness among community pharmacists is sub-optimal in Ibadan, Nigeria. Although practice when dealing with elderly customers was satisfactory, the knowledge was unsatisfactory. This underscores the need to intensify the awareness and use of guidelines that document specific PIMs such as Beers Criteria among community pharmacists.
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Akande-Sholabi W, Fafemi A. Potentially inappropriate medication use in the elderly: physicians' and hospital pharmacists knowledge, practice, confidence, and barriers. J Pharm Health Care Sci 2022; 8:36. [PMID: 36494676 PMCID: PMC9733080 DOI: 10.1186/s40780-022-00267-6] [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: 06/21/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Inappropriate medication prescribing and dispensing by physicians and pharmacists is a preventable cause of morbidity and mortality in the elderly. Signifying the importance of healthcare professionals' knowledge of potentially inappropriate prescribing tools/ guidelines which would improve overall health outcomes. Beers Criteria is one of the most used guidelines that list specific potentially inappropriate medications (PIMs). This study aimed to investigate physicians' and hospital pharmacists' awareness, knowledge, practice, confidence, and barriers to the use of Beers criteria. METHODS A cross-sectional survey was carried out among 66 hospital pharmacists and 31 family medicine physicians working in a teaching hospital in Nigeria, between May and September 2021 using a self-administered questionnaire. Knowledge of PIMs was assessed using 11 clinical vignettes based on the 2019 Beers Criteria. Practice behavior towards elderly patients was assessed using a 5-item statement with a 5-point Likert scale. Perceived barriers to the appropriate use of Beers Criteria were assessed using a 15-item statement. Descriptive and inferential statistics were used to analyze the data. RESULTS A total of 66 hospital pharmacists and 31 family medicine physicians participated in the study. Only (24; 36.4%) pharmacists and (4; 12.9%) physicians knew guidelines that listed specific PIMs. In all (21; 31.8%) pharmacists and (11; 35.4%) physicians demonstrated good knowledge of Beers Criteria, while most pharmacists (55; 83.3%) and physicians (29; 93.5%) reported good practice when dealing with elderly patients in terms of asking relevant questions and considering their ages while dispensing medications. Knowledge scores were not significantly associated with hospital pharmacists' socio-demographics. Most of the physicians and pharmacists were confident in the care provided for geriatric patients. The majority (66; 100.0%) pharmacists and (28; 93.5%) physicians suggested training through seminar presentations as a measure to improve the use of Beers' criteria. Lack of time to counsel patients was a major barrier recounted by both physicians and pharmacists. CONCLUSION Healthcare professionals that participated in this study had satisfactory practice, although a gap in the knowledge of hospital pharmacists and family medicine physicians was noted. In addition to creating awareness among healthcare professionals and training on PIMs and Beers' criteria, a multidisciplinary approach to reduce potentially inappropriate prescribing and dispensing would greatly help reduce the incidence of potentially inappropriate medication use among elderly patients.
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Affiliation(s)
- Wuraola Akande-Sholabi
- grid.9582.60000 0004 1794 5983Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
| | - Adeola Fafemi
- grid.9582.60000 0004 1794 5983Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
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Yuan J, Yin G, Gu M, Lu KZ, Jiang B, Li M. Physicians’ Knowledge, Altitudes, and Perceived Barriers of Inappropriate Prescribing for Older Patients in Shanghai, China. Front Pharmacol 2022; 13:821847. [PMID: 36071836 PMCID: PMC9441490 DOI: 10.3389/fphar.2022.821847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Inappropriate medication use is common around the world, particularly among older patients, and, despite potentially being preventable, often leads to adverse clinical and economic outcomes. However, there is a dearth of information regarding this prominent issue in China. Objectives: To evaluate the extent to which the physician can correctly identify potentially inappropriate medication (PIM) in older patients and to understand physicians’ attitudes towards improving PIM knowledge. Methods: An online, cross-sectional survey was conducted anonymously among practicing physicians in China from November through December 2020. Knowledge of PIM was accessed using seven clinical vignettes covering a wide variety of therapeutic areas. Source of information and perceived barriers regarding PIM were also evaluated. We performed the ordinary least square regression analysis to understand the potential factors related to physicians’ knowledge of PIM. Results: A total of 597 study participants were included in the analysis. More than half of them had never heard of any screening tool for PIMs (n = 328, 54.9%) and the most frequently acknowledged tool was the China PIM Criteria (n = 259, 43.4%). For the seven clinical vignettes testing physicians’ knowledge on the medications that should be generally avoided in older patients, the mean score was 2.91 points out of 7 (SD: 1.32), with the median score of three points (IQR: 2–4). Only one-third of the respondents were feeling confident when prescribing for older patients (n = 255, 35.08%). Package inserts have been used as the major source of PIM information (always, n = 177, 29.65%; frequently, n = 286, 47.91%). Perceived barriers to appropriate prescribing include polypharmacy (n = 460, 77.05%), lack of formal education on prescribing for the older patients (n = 428, 71.69%). Conclusion: In this online survey evaluating physicians’ ability to detect PIM for older patients, approximately 40% of PIM were recognized, suggesting an insufficient level of knowledge about appropriate prescribing.
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Affiliation(s)
- Jing Yuan
- Minhang Hospital and Department of Clinical Pharmacy at School of Pharmacy, Fudan University, Shanghai, China
| | - Guizhi Yin
- Department of Cardiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Meng Gu
- Minhang Hospital and Department of Clinical Pharmacy at School of Pharmacy, Fudan University, Shanghai, China
| | - Kevin Z. Lu
- University of South Carolina College of Pharmacy, Columbia, SC, United States
- *Correspondence: Kevin Z. Lu, ; Bin Jiang, ; Minghui Li,
| | - Bin Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- *Correspondence: Kevin Z. Lu, ; Bin Jiang, ; Minghui Li,
| | - Minghui Li
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, United States
- *Correspondence: Kevin Z. Lu, ; Bin Jiang, ; Minghui Li,
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Martinez KA, Linfield DT, Gupta NM, Alapati MV, Moussa D, Hu B, Kim LD, Lam S, Russo-Alvarez G, Rothberg MB. Patient and physician factors contributing to polypharmacy among older patients. Curr Med Res Opin 2022; 38:123-130. [PMID: 34544289 DOI: 10.1080/03007995.2021.1982683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Polypharmacy, or use of multiple medications, is associated with patient factors. Less is known regarding variation in polypharmacy by individual physicians. The objective of this study was to assess patient and physician factors associated with polypharmacy among older patients. METHODS This is a cross-sectional study of patients aged ≥65 years with a primary care visit at Cleveland Clinic Health System in 2015 and their physicians. We collected patient demographics, comorbidities and current medications from the electronic health record, including potentially inappropriate medications (PIMs). We used mixed effects linear regression to estimate adjusted differences in the number of medications by patient factors. We generated adjusted prescribing rates for individual physicians and assessed differences in physician performance on quality measures by their prescribing rate. RESULTS Our study included 44,570 patients who were prescribed an average of 6.8 medications (standard deviation: 4.0) by 701 physicians. Female sex, higher BMI, having Medicaid insurance, current or former smoking status, comorbidities and seeing a specialist were associated with number of medications. Age was not. Among 267 physicians who saw ≥20 study-eligible patients, the adjusted mean number of medications per patient ranged from 5.2 to 9.6. Compared to physicians who prescribed above the mean, lower prescribing physicians performed significantly better on medication reconciliation (p = .007) and hypertension control (p < .001) and prescribed fewer PIMs (p < .001). CONCLUSIONS Individual physicians varied in their prescribing practices, even after adjusting for patient demographic and clinical characteristics. Interventions to reduce polypharmacy in older adults should target high prescribing physicians, as physician behavior is more actionable than patient factors.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA
| | - Debra T Linfield
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Niyati M Gupta
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA
| | | | - Daniel Moussa
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Bo Hu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Luke Dogyun Kim
- Department of Geriatrics, Cleveland Clinic, Cleveland, OH, USA
| | - Simon Lam
- Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA
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Aguiar JP, Gama Marques J, Leufkens HGM, Alves da Costa F. Healthcare Professionals' Views on the Management of Medication Complexities in the Elderly With Mental Health Disorders: A Cross-Sectional Study. Front Psychiatry 2022; 13:885216. [PMID: 35677869 PMCID: PMC9168079 DOI: 10.3389/fpsyt.2022.885216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many challenges in elderly pharmacotherapy are identified, including the use of Potentially Inappropriate Medications (PIMs) which may increase the odds of adverse events, especially in elderly patients with mental health disorders (e. g., behavioral, and psychological symptoms of dementia-BPSD, schizophrenia, bipolar disorder). However, information on the knowledge and practice of healthcare professionals (HCPs) about this topic is still scarce. METHODS A cross-sectional study was undertaken from July-October 2019. An online questionnaire was specifically designed and validated for this study. We sought HCPs (physicians, pharmacists, and nurses) worldwide, using (a) social media, via Facebook, Twitter, and LinkedIn; and (b) email contacts of the research team (convenience sample). Either way participants were asked to share on their social media or via e-mail the questionnaires with other HCPs (snowballing sample). The survey assessed two main domains: knowledge and practice. Knowledge was evaluated by self-report (perceived knowledge by a 5-item Likert confidence scale) and using three clinical cases, scored between 0 and 30 points (each one rated from 0 to 10 points; real knowledge). Barriers in clinical practice were evaluated using a 5-item Likert scale judging practitioners' opinion. RESULTS A total of 165 questionnaires were collected. HCPs were mainly female (n = 114; 69.1%), with a mean age of 35.3 ± 11.3 years old. Seventy-two percent (n = 118) were pharmacists, 21.1% (n = 35) were physicians, and 7.3% (n = 12) nurses. There was a weak correlation, albeit significant, between perceived and real knowledge (r = 0.199; p = 0.001). The mean score of the clinical vignettes regarding elderly patients with dementia and bipolar disorder were 4.59 ± 4.08 and 4.86 ± 2.97 points, respectively. Most HCPs were classified as having an intermediate knowledge (n = 100; 60.6%) about medication complexities in the elderly with mental disorders. Most HCPs agreed that lack of time (81.6%; n = 138), lack of education and training on elderly pharmacotherapy (72.2%; n = 122), and lack of tools adapted to daily practice (61.8%; n = 105) were the main barriers. CONCLUSIONS Most of the HCPs felt confident to manage medication complexities in elder patients with mental disorders, but only a minority obtained a good score in the knowledge assessment test. The main barriers identified included structural barriers (tools unfit for practice) and process barriers (time).
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Affiliation(s)
- João Pedro Aguiar
- Research Institute for Medicines (iMED.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Caparica, Portugal
| | - João Gama Marques
- Serviço de Psiquiatria Geral e Transcultural, Centro Hospitalar Psiquiátrico de Lisboa (CHPL), Lisboa, Portugal.,Clínica Universitária de Psiquiatria e Psicologia Médica, Faculdade de Medicina, Universidade de Lisboa (FMUL), Lisboa, Portugal
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, Netherlands
| | - Filipa Alves da Costa
- Research Institute for Medicines (iMED.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz (IUEM), Caparica, Portugal
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Clinical Pharmacists' Knowledge of and Attitudes toward Older Adults. PHARMACY 2021; 9:pharmacy9040172. [PMID: 34698246 PMCID: PMC8544685 DOI: 10.3390/pharmacy9040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Although pharmacy literature suggests that pharmacists have a positive attitude towards older adults, there is a paucity of studies that have measured pharmacists’ knowledge or attitudes towards older people. The purpose of our study was to assess the knowledge and attitudes of hospital pharmacists toward older adults. Methods: An electronic survey was distributed over two months to clinical hospital pharmacists across the province of Alberta, Canada. The survey was composed of two validated tools, the Palmore Facts of Aging Quiz (PFAQ) and Kogan’s Attitude toward Old People Scale (KOPS). PFAQ is scored from 0 (poor knowledge) to 25 (high knowledge) and KOPS from 34 to 204, with higher than 119 indicating a positive attitude. Results: A total of 153 pharmacists completed the survey (response rate of 24%). The mean age was 39 (SD 10.8) years; the average years practiced was 15 (SD 11), and the majority of respondents (n = 65) reported that >50% of patients in their practice were geriatrics. The mean correct responses on the PFAQ were 18.8 (SD 2.6). KOPS had a mean score of 156.8 (SD 14), with only one pharmacist score falling below 119, indicating a negative attitude. There was a statistically significant, positive correlation between attitudes and knowledge (r = 0.38, p < 0.05), as well as the increasing age of the respondents (r = 0.18, p = 0.03). The remaining measured categories (i.e., gender, years of pharmacy practice) had no significant effect. Conclusion: Clinical hospital pharmacists in Alberta have a positive attitude toward geriatric patients, as well as a satisfactory knowledge of older adults.
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Lim D, Liu D, Burston B. Impacts of 2012 update to the AGS beers criteria on potentially inappropriate antipsychotic medication use among older adults. AGING AND HEALTH RESEARCH 2021. [DOI: 10.1016/j.ahr.2021.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Sharma R, Bansal P, Chhabra M, Arora M. Chronic kidney disease (CKD) -a brand ambassador/alarming bell for potentially inappropriate medication in elderly inpatients. Curr Aging Sci 2021; 15:59-64. [PMID: 34825648 DOI: 10.2174/1874609814666210719113157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/23/2021] [Accepted: 05/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the past decade, the prevalence of Potentially Inappropriate Medication (PIM) among elderly inpatients has increased drastically. However, limited data is available on PIM indicators, and PIMs use among the elderly in patients with Chronic Kidney Disease (CKD). OBJECTIVE To determine the prevalence of PIMs in elderly hospitalized patients with CKD. METHODS A cross-sectional study was carried out on 102 patients in a tertiary care hospital. PIMs were identified using Beers criteria 2019. A Chi-square test was used to determine the association between variables and PIMs use. RESULTS PIMs, as assessed according to AGS updated Beers criteria 2019 was found to be in more than 68.6% of patients of median age 65years and 3 number of diagnoses and seven days median length of stay. Most of the patients (47.1%) had ≥four diagnoses. The most common comorbidities in the patient were diabetes mellitus (n=54) and hypertension (n=55). Most of the subjects (66.7%) were on polypharmacy (5-9 medications/day), and 25.5% were on a higher level of polypharmacy (>10 medicines/day). Approximately 90% of the patients had very low CrCl < 21ml/min (calculated with the help of Cockcroft- Gault formula). A significant association between PIM use and an increased number of diagnoses, polypharmacy or high-level polypharmacy, was observed. CONCLUSION The prevalence of PIMs in elderly inpatients suffering from CKD is relatively high. The study indicates negligence/ lack of awareness amongst physicians leading to increase PIM use. The authors propose that the CKD patients should attract the special attention of the physician and should be treated as brand ambassadors or alarming bells for PIM use.
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Affiliation(s)
- Rishabh Sharma
- Department of Pharmacy Practice, Indo Soviet Friendship College of Pharmacy, Moga, Punjab. India
| | - Parveen Bansal
- University Centre of Excellence in Research, Baba Farid University of Health Sciences, Faridkot, Punjab. India
| | - Manik Chhabra
- Department of Pharmacy Practice, Indo Soviet Friendship College of Pharmacy, Moga, Punjab. India
| | - Malika Arora
- Multi-Disciplinary Research Unit, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. India
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Becerra AF, Boch M, Al-Mezrakchi YA. Ropinirole-Associated Orthostatic Hypotension as Cause of a Prescribing Cascade in an Elderly Man. Cureus 2021; 13:e15506. [PMID: 34268037 PMCID: PMC8261795 DOI: 10.7759/cureus.15506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Ropinirole is an overall well-tolerated antiparkinsonian medication that is also used to treat restless leg syndrome (RLS). The incidence of side effects is low, with orthostatic hypotension (OH) only anecdotally reported. Additionally, it is known that the elderly population is very susceptible to adverse drug effects and the prevalence of prescribing cascades that these can trigger is unknown. A 71-year-old male with history of atrial fibrillation, well-controlled diabetes on oral agents, hyperlipidemia, hypertension, ischemic heart failure status post (s/p) implantable cardioverter-defibrillator (ICD) placement with improved ejection fraction (EF), transient ischemic attack (TIA), rheumatoid arthritis, RLS, aortic stenosis s/p mechanical aortic valve replacement on anticoagulation, deep venous thrombosis (DVT), and right knee replacement, presented to the ED with generalized weakness, with difficulty standing from seated position, followed by a fall without head trauma. Over the eight months prior to this presentation, the patient had had similar symptoms that resulted in four falls, two hospital admissions, and new prescriptions of midodrine and compression stockings. On admission, vital signs were remarkable for positive orthostatics with blood pressure (BP) 110/74 mmHg, heart rate (HR) of 86 bpm in supine position and BP 87/51 mmHg, HR of 70 bpm while in standing position. Physical exam was unremarkable except for a known ejection murmur and dry oral mucous membranes. Labs included a creatinine 3.6 mg/dl, blood urea nitrogen (BUN) 66 mg/dl, international normalized ration (INR) of 4.1, B-natriuretic peptide (BNP) of 313 pg/mL, troponin <0.03 ng/mL. A kidney ultrasound was normal, and a transthoracic echocardiogram showed left ventricle ejection fraction (LVEF) of 55-65%, improved compared to a prior study. Furosemide, carvedilol and canagliflozin were discontinued and IV fluids were administered. In the subsequent days, his creatinine improved, and so did the patient's volume status, but he continued to be orthostatic despite midodrine and stockings. On further interview, the patient disclosed starting ropinirole 0.25 mg three times daily approximately 10 months prior to this admission, due to asymptomatic RLS that was reported in a sleep study. Decision was made to discontinue this medication, which resulted in improvement of symptoms. We were able to discontinue IV fluids, midodrine and stockings, and reintroduce carvedilol, furosemide and canagliflozin in a stepwise manner. In a follow-up visit one month after discharge, the patient was symptom-free. This case illustrates two major points. First, this prescribing cascade potentially induced by ropinirole, as well as the increase in health care costs associated to iatrogenic admissions, is major preventable problem faced mostly by the geriatric population. Second, although OH associated with ropinirole has only been reported in patients treated for Parkinson’s disease, this side effect should be considered when prescribing ropinirole for other indications, with cautious assessment of risks and benefits. Further studies need to be conducted to establish the frequency of OH related to ropinirole.
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Affiliation(s)
- Ana F Becerra
- Department of Medicine, University of Connecticut, Farmington, USA
| | - Marisa Boch
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Yahya A Al-Mezrakchi
- Department of Internal Medicine, Saint Francis Hospital, Trinity Health of New England (NE), Hartford, USA
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Isidoro GSP, Pinto MAV, Melo NCA, Souza PAMD, Silva LGRD, Sales TLS, Oliveira MG, Baldoni AO, Pestana ACNR, Chequer FMD. Potentially inappropriate medication use in older adults: prevalence and physician knowledge. GERIATRICS, GERONTOLOGY AND AGING 2021. [DOI: 10.5327/z2447-212320212000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE: To analyze the frequency, profile, and additional variables associated with the prescription of potentially inappropriate medications (PIM) to older adults in primary care, and evaluate physicians’ knowledge about these medications. METHODS: A cross-sectional study was conducted based on data from patient records for the period of January 2014 to December 2017 in a city located in the state of Minas Gerais. The frequency of PIM use was evaluated based on the 2019 Beers-Fick criteria. Physician knowledge was evaluated using a validated questionnaire as a primary data source. RESULTS: In a sample of 423 older adults, 75.89% (n = 321) used at least one PIM, the most common of which were medications used to treat central nervous system disorders (48.00%; n = 203). Most participants were female (62.41%; n = 264) and 70 years or older (69.50%; n = 294). When presented with clinical cases illustrating common situations in the management of older patients, 53.33% of physicians (n = 8) answered four or five questions correctly out of a possible seven; 13.33% (n = 2) answered six questions correctly; and 33.33% (n = 5) obtained three correct answers or fewer. CONCLUSIONS: These findings showed a high frequency of PIM use among older adults treated in Primary Health Care settings, with medications used in the treatment of central nervous system disorders. Our results highlight the importance of continuing education for health professionals and improved assessments of the medication available in the Unified Health System (Sistema Único de Saúde; SUS) for use in older adults, especially those taking multiple medications
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Potentially inappropriate prescribing in older hospitalized Dutch patients according to the STOPP/START criteria v2: a longitudinal study. Eur J Clin Pharmacol 2020; 77:777-785. [PMID: 33269418 PMCID: PMC8032616 DOI: 10.1007/s00228-020-03052-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/20/2020] [Indexed: 11/05/2022]
Abstract
Purpose To investigate prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in a population of older hospitalized patients. Methods A longitudinal study using a large dataset of hospital admissions of older patients (≥ 70 years) based on an electronic health records cohort including data from 2015 to 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) prevalence during hospital stay were identified based on the Dutch STOPP/START criteria v2. Univariate and multivariate logistic regression were used for analyzing associations and trends over time. Results The data included 16,687 admissions. Of all admissions, 56% had ≥ 1 PIM and 58% had ≥ 1 PPO. Gender, age, number of medications, number of diagnoses, Charlson score, and length of stay were independently associated with both PIMs and PPOs. Additionally, number of departments and number of prescribing specialties were independently associated with PIMs. Over the years, the PIM prevalence did not change (OR = 1.00, p = .95), whereas PPO prevalence increased (OR = 1.08, p < .001). However, when corrected for changes in patient characteristics such as number of diagnoses, the PIM (aOR = 0.91, p < .001) and PPO prevalence (aOR = 0.94, p < .001) decreased over the years. Conclusion We found potentially inappropriate prescriptions in the majority of admissions of older patients. Prescribing relatively improved over time when considering complexity of the admissions. Nevertheless, the high prevalence shows a clear need to better address this issue in clinical practice. Studies seeking effective (re)prescribing interventions are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-020-03052-2.
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Lau S, Lun P, Ang W, Tan KT, Ding YY. Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review. BMC Geriatr 2020; 20:459. [PMID: 33167898 PMCID: PMC7650160 DOI: 10.1186/s12877-020-01766-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. METHODS A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. RESULTS A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour. CONCLUSION The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
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Affiliation(s)
- Sabrina Lau
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Penny Lun
- Geriatric Education & Research Institute, Singapore, Singapore
| | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Keng Teng Tan
- Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- Geriatric Education & Research Institute, Singapore, Singapore
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Saka SA, Oosthuizen F, Nlooto M, Odusan O. The knowledge, awareness, and perception of healthcare professionals about appropriate prescribing in the elderly: Findings from Nigeria and South Africa. J Eval Clin Pract 2020; 26:1512-1521. [PMID: 31898394 DOI: 10.1111/jep.13347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Inappropriate prescribing is associated with preventable morbidity and mortality in the elderly. The American Geriatrics-Beers (AGS-Beers) Criteria was developed to guide healthcare professionals (HCPs) to prescribe medications appropriately in the elderly. However, there is a dearth of information about the knowledge and awareness of HCPs of these criteria, and their perceptions of appropriate prescribing in the elderly. This study aimed to evaluate the knowledge and perceptions of Nigerian and South African HCPs about appropriate prescribing in the elderly. METHOD A 32-item questionnaire was self-administered among consecutively selected HCPs (physicians, nurses, and pharmacists) in one teaching hospital each in Nigeria and South Africa. Seven questions including six clinical vignettes from the 2015 AGS-Beers Criteria were used to assess the participants' knowledge.The participants' knowledge was classified based on the total score as poor (0-3), fair (4, 5), and good (6, 7). The HCPs' perceptions of appropriate prescribing in the elderly were evaluated using a 5-point Likert scale. Mann-Whitney U test was used to evaluate ranked variables at P < .05. RESULTS A total of 369 participants, 62.9% (232/369) mean age 42.75(9.35) years in Nigeria and 37.1% (137/369), mean age 38.66 (7.76) years, (CI = 2.32-5.87, P < .001) in South Africa were evaluated. Many participants in Nigeria (52.6%) and 48.2% in South Africa had scores (4, 5).The majority of the participants (57.3%) in Nigeria and 67.2% in South Africa were not aware of any explicit criteria for prescribing to the elderly while 45.8% of the total participants with no significant difference between the groups (P = .332) "strongly agreed" or "agreed" that the basic professional training is adequate for prescribing medicines to the elderly. CONCLUSIONS Many HCPs in Nigeria and South Africa had a fair knowledge of appropriate prescribing to the elderly and considered basic professional training as adequate for appropriate prescribing to the elderly.
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Affiliation(s)
- Sule A Saka
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Frasia Oosthuizen
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Manimbulu Nlooto
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Olatunde Odusan
- Department of Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
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Akkawi ME, Nik Mohamed MH, Md Aris MA. The impact of a multifaceted intervention to reduce potentially inappropriate prescribing among discharged older adults: a before-and-after study. J Pharm Policy Pract 2020; 13:39. [PMID: 32695426 PMCID: PMC7367269 DOI: 10.1186/s40545-020-00236-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/31/2020] [Indexed: 01/02/2023] Open
Abstract
Background Potentially inappropriate prescribing (PIP) is associated with the incidence of adverse drug reactions, drug-related hospitalization and other negative outcomes in older adults. After hospitalization, older adults might be discharged with several types of PIPs. Studies have found that the lack of healthcare professionals' (HCPs) knowledge regarding PIP is one of the major contributing factors in this issue. The purpose of this study is to investigate the impact of a multifaceted intervention on physicians' and clinical pharmacists' behavior regarding potentially inappropriate medication (PIM) and potential prescribing omission (PPO) among hospitalized older adults. Methods This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app). Results The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03). Conclusions The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM.
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Affiliation(s)
- Muhammad Eid Akkawi
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Mohamad Haniki Nik Mohamed
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Mohd Aznan Md Aris
- Department of Family Medicine & Non-Communicable Disease Research Unit, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Malaysia
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Differences in Evaluating Fall Risk by Primary Care Provider Type. J Nurse Pract 2020; 16:528-532. [DOI: 10.1016/j.nurpra.2020.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Walker BS, Collier BR, Bower KL, Lollar DI, Faulks ER, Matos M, Nussbaum MS, Hamill ME. The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center. Am Surg 2020. [DOI: 10.1177/000313481908500842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM—73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.
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Affiliation(s)
- Benjamin S. Walker
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Bryan R. Collier
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Katie L. Bower
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Daniel I. Lollar
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Emily R. Faulks
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Miguel Matos
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Michael S. Nussbaum
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Mark E. Hamill
- From the Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Foong RTK, Sellappans R, Loo JSE. Awareness of Beers Criteria and knowledge of potentially inappropriate medications among community pharmacists in the Klang Valley, Malaysia. J Eval Clin Pract 2020; 26:165-171. [PMID: 31168913 DOI: 10.1111/jep.13180] [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] [Received: 03/18/2019] [Revised: 04/25/2019] [Accepted: 04/28/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) in older adults are detrimental to both clinical outcomes and health care costs, with their prominence set to increase in tandem with a fast-growing ageing population. Beers Criteria is one of the most commonly used guidelines that lists specific PIMs. Community pharmacists would therefore benefit from knowledge of Beers Criteria in detecting PIMs in primary care. This study therefore investigates the awareness of Beers Criteria and knowledge of PIMs among community pharmacists in the Klang Valley, Malaysia. METHODS The study was conducted using a self-administered questionnaire. Knowledge of PIMs was assessed using 10 clinical vignettes based on the 2015 Beers Criteria. Practice behaviour towards older customers was assessed using 10 items with a 5-point Likert scale. Descriptive and inferential statistics were used to analyse the data. RESULTS A total of 277 community pharmacists participated in the study. Only 27.1% of the pharmacists were aware of Beers Criteria, and of these, only 37.3% were aware of the latest 2015 update. The respondents demonstrated moderate knowledge of PIMs with a mean total score of 5.46 ± 1.89 out of a maximum of 10. Pharmacists who were aware of Beers Criteria had significantly higher scores (6.31 vs 5.14, P < .001). Only a small proportion of pharmacists (17.0%) regularly used Beers Criteria in practice. However, most pharmacists reported good practices when dealing with older customers in terms of asking relevant questions, considering age, referring to other resources, and regularly updating their knowledge through continuous professional development. CONCLUSION Awareness of Beers Criteria remains low among community pharmacists in Malaysia. Pharmacists who are aware of Beers Criteria have improved knowledge regarding PIMs in the older adults. There is a need to increase the awareness and use of Beers Criteria among community pharmacists.
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Affiliation(s)
- Ryan T K Foong
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Renukha Sellappans
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Jason S E Loo
- School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
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Fadare JO, Obimakinde AM, Enwere OO, Desalu OO, Ibidapo RO. Physician's Knowledge of Appropriate Prescribing for the Elderly-A Survey Among Family and Internal Medicine Physicians in Nigeria. Front Pharmacol 2019; 10:592. [PMID: 31214031 PMCID: PMC6554676 DOI: 10.3389/fphar.2019.00592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/08/2019] [Indexed: 02/02/2023] Open
Abstract
Background: Prescription and use of inappropriate medications have been identified as a major cause of morbidity among the elderly. Several screening tools have been developed to identify inappropriate medications prescribed for elderly patients. There is dearth of information about the knowledge of Nigerian physicians regarding these screening tools and appropriate prescribing for the elderly in general. The primary objective of this study was to assess the knowledge of Nigerian physicians about these screening tools and appropriate prescribing of medications for the elderly. Methods: The study was a cross-sectional questionnaire-based study conducted among physicians working in Family Medicine and Internal Medicine departments of four tertiary health care facilities in Nigeria. The questionnaire consisted of sections on general characteristics of respondents and their knowledge of four selected screening tools for inappropriate medications in the elderly. Ten clinical vignettes representing different therapeutic areas (using the best option type questions) about medicine use in the elderly were included with a score of 1 and 0 for correct and wrong answers, respectively. The knowledge of respondents was classified as (total score, over 10): poor (score, < 5), average (score, 5-6), and good (score, 7-10). Results: One hundred and five physicians returned completed questionnaires. Twenty percent of respondents knew about Beers criteria, whereas 15.6% were familiar with the STOPP criteria. Majority (83; 84.7%) of the respondents were confident of their ability to prescribeappropriately for elderly patients. The mean knowledge score was 5.3 ± 2.0 with 32 (30.5%), 41 (39%), and 32 (30.5%) having low, average, and good scores, respectively. The association between the knowledge score, duration of practice, and seniority was statistically significant (OR, 3.6, p = .004 and OR, 3; p = .012), respectively. Conclusion: There are significant gaps in the knowledge of Nigerian physicians about screening tools for inappropriate medications. There is a need for stakeholders involved in the care of elderly Nigerian patients to develop new strategies to improve services being offered. These may include introduction of modules on appropriate prescribing in the curriculum of undergraduate and postgraduate medical education and the routine use of some screening tools for inappropriate medications in daily clinical practice.
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Affiliation(s)
- Joseph O Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University College of Medicine, Ado-Ekiti, Nigeria
| | - Abimbola Margaret Obimakinde
- Family Medicine Unit, Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Family Medicine Department, University College Hospital, Ibadan, Nigeria
| | | | - Olufemi O Desalu
- Department of Medicine, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
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Mortazavi SS, Shati M, Malakouti SK, Khankeh HR, Mehravaran S, Ahmadi F. Physicians' role in the development of inappropriate polypharmacy among older adults in Iran: a qualitative study. BMJ Open 2019; 9:e024128. [PMID: 31122964 PMCID: PMC6538096 DOI: 10.1136/bmjopen-2018-024128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The use of unnecessary or excessive medications (inappropriate polypharmacy) is a major health challenge among older adults which is driven by several factors. This study aims to provide in-depth descriptions of the physician's role in the development of inappropriate polypharmacy among older adults in Iran. DESIGN Qualitative content analysis of interviews, field notes and other relevant documents available (eg, medical records). Data collection and analyses were done concurrently to guide the sampling process. SETTING Three purposively selected referral hospitals in Tehran, Iran. PARTICIPANTS A total of 7 physicians, 10 older adults, 3 caregivers and 3 pharmacists with a median age of 54 (IQR 23) years were recruited through convenience sampling. RESULTS Emerged categories included misdiagnosis, inappropriate prescribing, insufficient patient education, poor communication, unprofessional behaviour and limited perspectives which highlight the role of physicians in the development of inappropriate polypharmacy among older adults in Iran under the main concept of poor medical practice. CONCLUSION This study provides valuable insight on the role of physicians in the development of inappropriate polypharmacy among the elderly in the healthcare setting in Iran by exploring the viewpoints of physicians, patients, caregivers and pharmacists. Physicians can be an influential factor in tackling this challenge through proper diagnosis, prescription, patient education and follow-up. In Iran, physicians' practice styles are affected by potentially adverse factors such as the novelty of geriatric medicine, lack of a referral system, patient unfamiliarity with the system and lack of a monitoring system for multiple prescriptions. Furthermore, clinics tend to be overcrowded and visit fees can be low; in this setting, lack of physician assistants leads to limited time allocation to each patient and physician dissatisfaction with their income.
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Affiliation(s)
- Seyede Salehe Mortazavi
- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Shati
- Mental Health Research Center, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Kazem Malakouti
- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Khankeh
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran
| | - Shiva Mehravaran
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, USA
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Abstract
BACKGROUND AND PURPOSE The elderly population is expected to double by 2050 with falls and hospitalizations due to adverse drug events having a major effect on health and quality of life. With the release of the revised 2015 American Geriatrics Society (AGS) Beers criteria, usage of potentially inappropriate medications (PIMs) should be studied to determine their effect on falls and hospitalizations in frail populations such as those in assisted living facilities. METHODS This quality improvement project used a retrospective chart review on residents from a purposive sample of two assisted living facilities in Northern Virginia. Residents were aged ≥65 and lived at the facility for at least 6 months and were not enrolled in hospice and/or palliative care or living in the dementia unit. The 2015 AGS Beers criteria were used to evaluate the effect of PIMs on falls and hospitalization rates. CONCLUSIONS This project did not find statistical significance between PIMs and falls (p = .276). A favorable, but not statistically significant trend, was noted between PIMs and hospitalizations (p = .079). IMPLICATIONS FOR PRACTICE Understanding the effect of PIMs on falls and hospitalizations could help providers improve prescribing practices for the elderly population who are at the greatest risk for potential adverse effects from polypharmacy.
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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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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
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, 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
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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Najjar MF, Sulaiman SAS, Al Jeraisy M, Balubaid H. The impact of a combined intervention program: an educational and clinical pharmacist's intervention to improve prescribing pattern in hospitalized geriatric patients at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Ther Clin Risk Manag 2018; 14:557-564. [PMID: 29588595 PMCID: PMC5859904 DOI: 10.2147/tcrm.s157469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background There is a difference between evidence-based guidelines for geriatric patients and clinical practice of physicians. Prescribing potentially inappropriate medications (PIMs) can be attributed to the fact that many physicians are not aware of PIMs usage. Aim The aim of this study was to assess the effectiveness of a combined intervention program comprising an educational and clinical pharmacist intervention to reduce the incidence of PIMs among hospitalized geriatric patients. Methods This was a prospective pre-test versus post-test design study. The screening tool of older persons’ prescriptions, 2nd version, and 2015 American Geriatric Society Beers’ criteria were used to assess the appropriateness of medications prescribed for geriatric inpatients. The study was carried out in the medical wards of the Department of Medicine at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Results Four hundred geriatric patients were enrolled in the study: 200 in a pre-intervention group (control) and 200 in the intervention group. After the combined intervention, the incidence rate of PIMs decreased significantly from 61% to 29.5% (p<0.001). Out of 317 recommendations given by the clinical pharmacist, the physicians accepted a total of 196 (61.83%) recommendations. The most common PIMs to avoid regardless of diagnosis of geriatric patients before interventions were first-generation antihistamines (46%), sliding scale insulin (18.5%), antipsychotics (6.5%), benzodiazepines (9.5%), and antiarrhythmic drugs (15%). Conclusion Using a combined intervention program that comprises an educational intervention of updated evidence-based guidelines and clinical pharmacist intervention would add a significant value to improve prescribing patterns in hospitalized geriatric patients.
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Affiliation(s)
- Muath Fahmi Najjar
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Science, College of Pharmacy, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,Pharmaceutical Sciences School, Clinical Pharmacy Discipline, Universiti Sains Malaysia, Penang, Malaysia
| | - Syed Azhar Syed Sulaiman
- Pharmaceutical Sciences School, Clinical Pharmacy Discipline, Universiti Sains Malaysia, Penang, Malaysia
| | - Majed Al Jeraisy
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Science, College of Pharmacy, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hashim Balubaid
- King Abdullah International Medical Research Centre, King Saud bin Abdulaziz University for Health Science, College of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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26
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Akkawi ME, Nik Mohamed MH. Are physicians and clinical pharmacists aware and knowledgeable enough about inappropriate prescribing for elderly patients? Findings from Malaysia. Eur J Hosp Pharm 2018; 25:e29-e34. [PMID: 31157063 PMCID: PMC6457149 DOI: 10.1136/ejhpharm-2017-001391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To assess the knowledge of physicians and clinical pharmacists about inappropriate prescribing for elderly patients, their confidence in prescribing for elderly patients, and their perceptions of barriers to appropriate prescribing in this population. METHODS A cross-sectional study using a validated 20-item questionnaire was conducted among physicians (n=78) and clinical pharmacists (n=45) working in the medical wards of two tertiary hospitals in Malaysia. Knowledge was assessed by six clinical vignettes which were developed based on Beers criteria and the STOPP/START criteria. Other domains of the study were investigated using a four-point or five-point Likert scale. RESULTS Of the 82 participants who completed the questionnaire, 65% were physicians, 90.2% had never received training in geriatric medicine, and 70.8% estimated that 25% or more of their patients were elderly. Only six participants (7.3%) had ever used STOPP/START or Beers criteria when prescribing for elderly patients, and 60% of the respondents had never heard of either one of those criteria. The mean score (SD) for the knowledge part was 3.65 (1.46) points, and only 27 participants (22.9%) scored more than four out of a possible six points. Overall, 34% of the participants rated themselves as confident in prescribing for elderly patients, and this was significantly associated with their knowledge score (P=0.02). The mean number (SD) of barriers cited per participant was 6.88 (2.84), with polypharmacy being the most cited barrier. CONCLUSIONS The majority of the participants had inadequate knowledge and low confidence regarding recommending medications for elderly patients. Continuing education on geriatric pharmacotherapy may be of value for the hospital physicians and pharmacists.
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Affiliation(s)
- Muhammad Eid Akkawi
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohamad Haniki Nik Mohamed
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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Al Khaja KA, Ahmed Isa H, Veeramuthu S, Sequeira RP. Potentially Inappropriate Prescribing in Older Adults with Hypertension or Diabetes Mellitus and Hypertension in a Primary Care Setting in Bahrain. Med Princ Pract 2018; 27:241-249. [PMID: 29495011 PMCID: PMC6062721 DOI: 10.1159/000488055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/01/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The aims of this study were to evaluate: (1) the prevalence and types of potentially inappropriate prescribing in older adults with hypertension or diabetes mellitus and hypertension, and (2) whether or not differences in the training of primary care physicians were associated with potentially inappropriate prescribing. MATERIALS AND METHODS Primary care prescriptions issued by family physicians and general practitioners were audited using Screening Tool of Older Persons' Prescriptions criteria (version 1), with 18 out of 65 applicable criteria. Descriptive statistics were used to test the difference between proportions, and two-tailed t test was used for continuous variables. RESULTS A total of 2,090 outpatient prescriptions were written during the study period; of these, 712 (34.1%) were potentially inappropriate. The mean number of drugs per patient was 6.03 (±2.5). Of the 712 prescriptions, 543 (76.3%) were used for the treatment of acute medical illnesses. The most common examples of potentially inappropriate prescribing were: orphenadrine (n = 174; 8.33%), long-term nonsteroidal anti-inflammatory drugs for > 3 months (n = 150; 7.18%), proton pump inhibitors for > 8 weeks (n = 135; 6.46%), antihypertensive therapy duplication (n = 59; 2.82%), long-acting glyburide (n = 48; 2.29%), and chlordiazepoxide for > 1 month (n = 44; 2.11%). Family physicians showed a greater tendency toward potentially inappropriate prescribing compared to general practitioners, but the difference was nonsignificant (n = 514 [34.75%] vs. n = 162 [31.3%]; p = 0.16). CONCLUSIONS The prevalence of potentially inappropriate prescribing (i.e., 34.1%) was within the spectrum reported worldwide and unrelated to the training backgrounds of physicians. Most of the identified potentially inappropriate prescribing (76.3%) in older adults was associated with medications for acute medical illnesses and hence inappropriate polypharmacy should be discouraged.
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Affiliation(s)
- Khalid A.J. Al Khaja
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrein
- *Prof. Khalid A.J. Al Khaja, PhD, Department of Pharmacology and Therapeutics, Arabian Gulf University, PO Box 22979, Manama (Kingdom of Bahrain), E-Mail
| | | | - Sindhan Veeramuthu
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrein
| | - Reginald P. Sequeira
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrein
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Moss JM, Bryan WE, Wilkerson LM, King HA, Jackson GL, Owenby RK, Van Houtven CH, Stevens MB, Powers J, Vaughan CP, Hung WW, Hwang U, Markland AD, Sloane R, Knaack W, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department. J Pharm Pract 2017; 32:167-174. [PMID: 29277130 DOI: 10.1177/0897190017747424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
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Affiliation(s)
- Jason M Moss
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,2 Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E Bryan
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Loren M Wilkerson
- 4 Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Heather A King
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - George L Jackson
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Ryan K Owenby
- 3 Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H Van Houtven
- 5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
| | - Melissa B Stevens
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - James Powers
- 9 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, TN, USA.,10 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Camille P Vaughan
- 7 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA.,8 Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - William W Hung
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ula Hwang
- 11 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA.,12 Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | | | - Richard Sloane
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,14 Department of Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - William Knaack
- 15 Division of General Internal Medicine, Veterans Affairs Health Care System, Durham, NC, USA
| | - Susan Nicole Hastings
- 1 Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA.,5 Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA.,6 Duke University School of Medicine, Durham, NC, USA
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Turner JP, Tannenbaum C. Older Adults' Awareness of Deprescribing: A Population-Based Survey. J Am Geriatr Soc 2017; 65:2691-2696. [PMID: 28913911 PMCID: PMC5763385 DOI: 10.1111/jgs.15079] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objectives To determine older adults’ awareness of the concept of medication‐induced harm and their familiarity with the term “deprescribing.” Secondary objectives were to ascertain determinants of self‐initiated deprescribing conversations and to identify how older adults seek information on medication harms. Design Cross‐sectional population‐based household telephone survey using random‐digit dialling. Setting Canada. Participants Community‐dwelling adults aged 65 and older (N = 2,665; n = 898 men, n = 1,767 women, mean age 74.9 ± 7.2, range 65–100). Measurements Information was gathered on age; sex; awareness of the term “deprescribing”; knowledge and information‐seeking behaviors related to medication harms; and previous initiation of a deprescribing conversation with a healthcare professional. Three targeted classes of potentially inappropriate prescriptions were asked about: sedative‐hypnotics, glyburide, and proton pump inhibitors. Descriptive statistics and regression analyses were used to quantify associations. Results Two‐thirds (65.2%, 95% confidence interval (CI) = 63.4–67.0%) of participants were familiar with the concept of medication‐induced harms. Only 6.9% (95% CI = 5.9–7.8%) recognized the term deprescribing; 48% (95% CI = 46–50%) had researched medication‐related harms. Older adults most commonly sought information from the Internet (35.5%, 95% CI = 33.4–37.6%), and from health care professionals (32.2%, 95% CI = 30.1–34.3%). Patient‐initiated deprescribing conversations were associated with awareness of medication harms (odds ratio (OR) = 1.74, 95% CI = 1.46–2.07), familiarity with the term deprescribing (OR = 1.55, 95% CI = 1.13–2.12), and information‐seeking behaviors (OR = 4.57, 95% CI = 3.84–5.45), independent of age and sex. Conclusion Healthcare providers can facilitate patient‐initiated deprescribing conversations by providing information on medication harms and using the term “deprescribing.”
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Affiliation(s)
- Justin P Turner
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada.,Faculté de Pharmacie, Université de Montréal, Montréal, Quebec, Canada
| | - Cara Tannenbaum
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada.,Faculté de Pharmacie, Université de Montréal, Montréal, Quebec, Canada.,Faculté de Médicine, Université de Montréal, Montréal, Quebec, Canada
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30
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Nothelle SK, Sharma R, Oakes AH, Jackson M, Segal JB. Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review. J Am Med Dir Assoc 2017; 18:806.e1-806.e17. [PMID: 28764876 DOI: 10.1016/j.jamda.2017.06.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized. METHODS We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data. RESULTS Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians. CONCLUSIONS Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.
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Affiliation(s)
- Stephanie K Nothelle
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Ritu Sharma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allison H Oakes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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Pek EA, Remfry A, Pendrith C, Fan-Lun C, Bhatia RS, Soong C. High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among Hospitalized Older Adults. J Hosp Med 2017; 12:310-316. [PMID: 28459898 DOI: 10.12788/jhm.2739] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions. OBJECTIVE To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions. DESIGN Single-center retrospective observational study. SETTING Urban academic medical center. PARTICIPANTS Medical-surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone. MEASUREMENTS Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random-intercept logistic regression model to identify patient- and prescriber-level variables that were associated with potentially inappropriate prescriptions. RESULTS Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70-16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first-year trainees (OR, 0.28; 95% CI, 0.08-0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21-9.06). CONCLUSIONS The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first-year trainees.Journal of Hospital Medicine 2017;12:310-316.
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Affiliation(s)
| | - Andrew Remfry
- Department of Medicine, University of Toronto, Ontario
| | - Ciara Pendrith
- Institute of Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario
| | - Chris Fan-Lun
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Ontario; Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario; Division of Cardiology, Women's College Hospital and University Health Network, Toronto, Ontario; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Christine Soong
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario; Division of General Internal Medicine, Sinai Health System, Toronto, Ontario; Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario
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Voigt K, Gottschall M, Köberlein-Neu J, Schübel J, Quint N, Bergmann A. Why do family doctors prescribe potentially inappropriate medication to elderly patients? BMC FAMILY PRACTICE 2016; 17:93. [PMID: 27449802 PMCID: PMC4957869 DOI: 10.1186/s12875-016-0482-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 07/13/2016] [Indexed: 01/18/2023]
Abstract
Background Based on changes in pharmacokinetics and –dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited. Methods This mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs’ medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed. Results Content analysis of 1846 patients’ records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics. Conclusions It is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs’ experiences in daily practice, FPs’ knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs’ daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs’ advanced training.
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Affiliation(s)
- Karen Voigt
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany.
| | - Mandy Gottschall
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
| | - Juliane Köberlein-Neu
- Department of Health Care Management and Public Health, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Jeannine Schübel
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
| | - Nadine Quint
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
| | - Antje Bergmann
- Department of General Practice/Medical Clinic III, Medical School, Technische Universität Dresden, Dresden, Germany
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Kydd A, Fleming A. What doctors need to know: Prescribing or not for the oldest old. Maturitas 2016; 90:9-16. [PMID: 27282788 DOI: 10.1016/j.maturitas.2016.05.003] [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] [Received: 04/17/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.
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Affiliation(s)
- Angela Kydd
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom.
| | - Anne Fleming
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom
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Fadare JO, Desalu OO, Obimakinde AM, Adeoti AO, Agboola SM, Aina FO. Prevalence of inappropriate medication prescription in the elderly in Nigeria: A comparison of Beers and STOPP criteria. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2015; 27:177-89. [DOI: 10.3233/jrs-150660] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joseph O. Fadare
- Department of Pharmacology, Ekiti State University, Ado-Ekiti, Nigeria
| | | | - Abimbola M. Obimakinde
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | | | - Segun M. Agboola
- Department of Family Medicine, Federal Medical Centre, Ido-Ekiti, Nigeria
| | - Felix O. Aina
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
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Brinkman DJ, Keijsers CJPW, Tichelaar J, Richir MC, van Agtmael MA. Evaluating pharmacotherapy education: urgent need for hard outcomes. Br J Clin Pharmacol 2015; 81:1000-1. [PMID: 26663464 DOI: 10.1111/bcp.12862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/27/2015] [Accepted: 12/07/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- David J Brinkman
- Research and Expertise Center In Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Jelle Tichelaar
- Research and Expertise Center In Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands
| | - Milan C Richir
- Research and Expertise Center In Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Research and Expertise Center In Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.,Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, The Netherlands
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Steinman MA, Beizer JL, DuBeau CE, Laird RD, Lundebjerg NE, Mulhausen P. How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors. J Am Geriatr Soc 2015; 63:e1-e7. [PMID: 26446776 PMCID: PMC5325682 DOI: 10.1111/jgs.13701] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a "warning light" to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California at San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Judith L Beizer
- College of Pharmacy and Health Sciences, St. John's University, Queens, New York
| | - Catherine E DuBeau
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Massachusetts
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The relevance of educating doctors, pharmacists and older patients about potentially inappropriate medications. Int J Clin Pharm 2015; 37:971-4. [DOI: 10.1007/s11096-015-0203-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sellappans R, Lai PSM, Ng CJ. Challenges faced by primary care physicians when prescribing for patients with chronic diseases in a teaching hospital in Malaysia: a qualitative study. BMJ Open 2015; 5:e007817. [PMID: 26316648 PMCID: PMC4554910 DOI: 10.1136/bmjopen-2015-007817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify the challenges faced by primary care physicians (PCPs) when prescribing medications for patients with chronic diseases in a teaching hospital in Malaysia. DESIGN/SETTING 3 focus group discussions were conducted between July and August 2012 in a teaching primary care clinic in Malaysia. A topic guide was used to facilitate the discussions which were audio-recorded, transcribed verbatim and analysed using a thematic approach. PARTICIPANTS PCPs affiliated to the primary care clinic were purposively sampled to include a range of clinical experience. Sample size was determined by thematic saturation of the data. RESULTS 14 family medicine trainees and 5 service medical officers participated in this study. PCPs faced difficulties in prescribing for patients with chronic diseases due to a lack of communication among different healthcare providers. Medication changes made by hospital specialists, for example, were often not communicated to the PCPs leading to drug duplications and interactions. The use of paper-based medical records and electronic prescribing created a dual record system for patients' medications and became a problem when the 2 records did not tally. Patients sometimes visited different doctors and pharmacies for their medications and this resulted in the lack of continuity of care. PCPs also faced difficulties in addressing patients' concerns, and dealing with patients' medication requests and adherence issues. Some PCPs lacked time and knowledge to advise patients about their medications and faced difficulties in managing side effects caused by the patients' complex medication regimen. CONCLUSIONS PCPs faced prescribing challenges related to patients, their own practice and the local health system when prescribing for patients with chronic diseases. These challenges must be addressed in order to improve chronic disease management in primary care and, more importantly, patient safety.
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Affiliation(s)
- Renukha Sellappans
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
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Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol 2015; 78:738-47. [PMID: 24661192 DOI: 10.1111/bcp.12386] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/20/2014] [Indexed: 12/30/2022] Open
Abstract
Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term 'deprescribing' has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.
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Affiliation(s)
- Emily Reeve
- Sansom Institute, 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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Bell HT, Steinsbekk A, Granas AG. Factors influencing prescribing of fall-risk-increasing drugs to the elderly: A qualitative study. Scand J Prim Health Care 2015; 33:107-14. [PMID: 25965505 PMCID: PMC4834497 DOI: 10.3109/02813432.2015.1041829] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Explore the situations in which GPs associate drug use with falls among their elderly patients, and the factors influencing the prescribing and cessation of fall-risk-increasing drugs (FRIDs). DESIGN A qualitative study with 13 GPs who participated in two semi-structured focus groups in Central Norway. Participants were encouraged to share overall thoughts on the use of FRIDs among elderly patients and stories related to prescribing and cessation of FRIDs in their own practice. RESULTS The main finding was that GPs did not immediately perceive the use of FRIDs to be a prominent factor regarding falls in elderly patients, exceptions being when the patient presented with dizziness, reported a fall, or when prescribing FRIDs for the first time. It was reported as common to renew prescriptions without performing a drug review. Factors influencing the prescribing and cessation of FRIDs were categorized into GPs' clinical work conditions, uncertainty about outcome of changing prescriptions, patients' prescribing demands, and lack of patient information. CONCLUSIONS The results from this study indicate that GPs need to be reminded that there is a connection between FRID use and falls among elderly patients of enough clinical relevance to remember to assess the patient's drug list and perform regular drug reviews.
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Affiliation(s)
- Hege Therese Bell
- Correspondence: Hege Therese Bell, Høgskolen iNord-Trøndelag, Finn Christensens veg 1, NO-7800 Namsos, Norway. Tel: + 47 920 80 915. E-mail:
| | - Aslak Steinsbekk
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Gerd Granas
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo and Akershus University College, Oslo, Norway
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Stock S, Redaelli M, Simic D, Siegel M, Henschel F. Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly : an analysis of sickness fund routine claims data from Germany. Wien Klin Wochenschr 2014; 126:604-12. [PMID: 25216754 DOI: 10.1007/s00508-014-0589-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 08/09/2014] [Indexed: 12/25/2022]
Abstract
Elderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.
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Affiliation(s)
- Stephanie Stock
- Institut für Gesundheitsökonomie und Klinische Epidemiologie der Universität zu Köln, Gleueler Str. 176-178, 50935, Köln, Germany,
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Sehgal V, Bajwa SJS, Sehgal R, Bajaj A, Khaira U, Kresse V. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. J Family Med Prim Care 2014; 2:194-9. [PMID: 24479078 PMCID: PMC3894035 DOI: 10.4103/2249-4863.117423] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aim: Readmission to the hospital within 30 days of discharge from the hospital is a common occurrence. Congestive heart failure is the most common cause of readmissions in the hospital. We hypothesized that irrespective of the admission diagnosis polypharmacy and potentially inappropriate use of medications (PIM) leads to readmissions within 30 days of discharge from the hospital. Materials and Methods: A retrospective study was carried out by reviewing the hospital records of 414 patients who were readmitted to the hospital within 30 days of discharge from the hospital between January 2008 and December 2009. The data was stratified to see which patients were on polypharmacy and/or on PIM. Polypharmacy was defined as use of more than 5 medications. PIM was defined as per the modified Beers criteria. Day 0 was defined as the day of discharge and day1 was defined as the day-after Admission to the hospital. Statistical analysis was carried out using a two-way analysis of variance (ANOVA) on the data to see if polypharmacy and/or PIM was related to readmission within 30 days of discharge irrespective of admission diagnosis. Results: Polypharmacy was related to hospital readmission at day 1 and day 0, however inappropriate drug use was found to be not related at any day. Polypharmacy and PIM combined had a positive correlation to readmission only on days 1 and 0 and it was statistically significant. The use of minimal and appropriate use of drugs was statistically significant compared to polypharmacy and PIM use. Conclusions: Polypharmacy and PIM are under recognized cause of readmissions to the hospital.
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Affiliation(s)
- Vishal Sehgal
- Department of Medicine The Commonwealth Medical College, Scranton, USA
| | | | - Rinku Sehgal
- Wright Center Graduate Medical Education, Scranton, USA
| | - Anurag Bajaj
- Wright Center Graduate Medical Education, Scranton, USA
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The impact of combined use of fall-risk medications and antithrombotics on injury severity and intracranial hemorrhage among older trauma patients. Geriatr Nurs 2014; 35:20-5. [DOI: 10.1016/j.gerinurse.2013.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 08/26/2013] [Accepted: 09/01/2013] [Indexed: 11/18/2022]
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Clyne B, Bradley MC, Hughes CM, Clear D, McDonnell R, Williams D, Fahey T, Smith SM. Addressing potentially inappropriate prescribing in older patients: development and pilot study of an intervention in primary care (the OPTI-SCRIPT study). BMC Health Serv Res 2013; 13:307. [PMID: 23941110 PMCID: PMC3751793 DOI: 10.1186/1472-6963-13-307] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 08/12/2013] [Indexed: 11/17/2022] Open
Abstract
Background Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over €45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care. Methods The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial. Results The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets. Conclusions The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland.
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Hsiao FY, Hsieh PH, Gau CS. Ten-year trend in prescriptions of z-hypnotics among the elderly: A nationwide, cross-sectional study in Taiwan. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.jcgg.2012.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Clyne B, Bradley MC, Smith SM, Hughes CM, Motterlini N, Clear D, McDonnell R, Williams D, Fahey T. Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol). Trials 2013; 14:72. [PMID: 23497575 PMCID: PMC3621288 DOI: 10.1186/1745-6215-14-72] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/27/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care. METHODS/DESIGN This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted. DISCUSSION This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges. TRIAL REGISTRATION Current controlled trials ISRCTN41694007.
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Affiliation(s)
- Barbara Clyne
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Marie C Bradley
- School of Pharmacy, Queen’s University Belfast (QUB), University Road, Belfast Northern BT7 1NN, Ireland
| | - Susan M Smith
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen’s University Belfast (QUB), University Road, Belfast Northern BT7 1NN, Ireland
| | - Nicola Motterlini
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Daniel Clear
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - Ronan McDonnell
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland (RCSI), Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Tom Fahey
- Health Research Board (HRB) Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Beaux Lane House, Lower Mercer Street, Dublin, Ireland
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Russett F. Recent Publications on Medications and Pharmacy. Hosp Pharm 2012. [DOI: 10.1310/hpj4702-156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.
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Affiliation(s)
- Flint Russett
- Department of Pharmacy and Drug Information, St. Claire Regional Medical Center, Morehead, Kentucky
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