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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Alaa Eddine N, Schreiber J, El-Yazbi AF, Shmaytilli H, Amin MEK. A pharmacist-led medication review service with a deprescribing focus guided by implementation science. Front Pharmacol 2023; 14:1097238. [PMID: 36794277 PMCID: PMC9922726 DOI: 10.3389/fphar.2023.1097238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65 years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.
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Affiliation(s)
- Nada Alaa Eddine
- Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon,*Correspondence: Nada Alaa Eddine, ; Mohamed Ezzat Khamis Amin,
| | - James Schreiber
- School of Nursing, Duquesne University, Pittsburgh, PA, United States
| | - Ahmed F. El-Yazbi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt,Faculty of Pharmacy, Alamein International University, El Alamein, Egypt
| | - Haya Shmaytilli
- Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
| | - Mohamed Ezzat Khamis Amin
- Faculty of Pharmacy, Alamein International University, El Alamein, Egypt,*Correspondence: Nada Alaa Eddine, ; Mohamed Ezzat Khamis Amin,
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Lee S, Bobb Swanson M, Fillman A, Carnahan RM, Seaman AT, Reisinger HS. Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study. J Am Geriatr Soc 2023; 71:62-76. [PMID: 36258309 PMCID: PMC10092723 DOI: 10.1111/jgs.18047] [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: 04/18/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed. METHODS We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes. RESULTS Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations. CONCLUSIONS Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Allison Fillman
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Aaron T Seaman
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Kegler MC, Rana S, Vandenberg AE, Hastings SN, Hwang U, Eucker SA, Vaughan CP. Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments. FRONTIERS IN HEALTH SERVICES 2022; 2:1053489. [PMID: 36925898 PMCID: PMC10012623 DOI: 10.3389/frhs.2022.1053489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
Background Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Materials and methods Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Results Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Discussion Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. Conclusion This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.
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Affiliation(s)
- Michelle C. Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Shaheen Rana
- School of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | | | - Ula Hwang
- Yale University School of Medicine, New Haven, CT, United States
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Bai I, Isenor JE, Reeve E, Whelan AM, Martin-Misener R, Burgess S, Kennie-Kaulbach N. Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs. Res Social Adm Pharm 2021; 18:3350-3357. [PMID: 34895842 DOI: 10.1016/j.sapharm.2021.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. OBJECTIVES To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. METHODS Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. RESULTS Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. CONCLUSIONS This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.
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Affiliation(s)
- Isaac Bai
- Faculty of Medicine, Dalhousie University, 5849 University Ave, Halifax, NS, Canada
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
| | - Sarah Burgess
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
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Stoll JA, Ranahan M, Richbart MT, Brennan-Taylor MK, Taylor JS, Brady L, Cal J, Baumgartner A, Wahler RG, Singh R. Development of video animations to encourage patient-driven deprescribing: A Team Alice Study. PATIENT EDUCATION AND COUNSELING 2021; 104:2716-2723. [PMID: 33994020 PMCID: PMC9237954 DOI: 10.1016/j.pec.2021.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/10/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community. METHODS Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development. RESULTS Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital." CONCLUSION The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves. PRACTICE IMPLICATIONS Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.
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Affiliation(s)
- Jennifer A Stoll
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA.
| | - Molly Ranahan
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Michael T Richbart
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Mary K Brennan-Taylor
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - John S Taylor
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Laura Brady
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Joseph Cal
- Spokesman of Elder Voices Elder Voices, Primary Care Research Institute, UB Downtown Gateway Department of Family Medicine, Buffalo, USA
| | - Andrew Baumgartner
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Robert G Wahler
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Ranjit Singh
- Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
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Visscher BB, Vervloet M, Te Paske R, van Dijk L, Heerdink ER, Rademakers J. Implementation of an animated medication information tool in community pharmacies, with a special focus on patients with limited health literacy. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:566-572. [PMID: 34427591 DOI: 10.1093/ijpp/riab038] [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: 02/03/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The animated medication information tool 'Watchyourmeds' provides information in an accessible manner through animated videos and therefore appears to be especially suitable for people with limited health literacy. This study aimed to assess the implementation of this animated medication information tool in Dutch community pharmacies, with a special focus on patients with limited health literacy. METHODS A cross-sectional survey based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was sent to approximately 75% of the ±1900 community pharmacies in the Netherlands through email newsletters of pharmacy networks. KEY FINDINGS 140 pharmacists (⁓10%) completed the survey and 125 of them (89%) indicated that they offered the animated medication information tool to their patients. 108 pharmacists indicated that the tool was offered to all patients, not only to patients with limited health literacy. The distribution method was primarily passive (patients were given a leaflet and were not explicitly pointed to or informed about the tool). Two frequently cited motivations for offering the tool were that it complemented other sources of information and that the health insurer provided a financial incentive. The main reasons patients refused to use the tool were that they had no access to or no affinity for the required technology. CONCLUSIONS This study demonstrated that the tool is used in community pharmacies and that it is offered to all patients, regardless of their presumed health literacy level. A more active method of offering the tool may be warranted to better reach patients with limited health literacy.
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Affiliation(s)
- Boudewijn B Visscher
- Researchgroup Innovations in Pharmaceutical Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Roland Te Paske
- Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,Department of PharmacoTherapy, -Epidemiology, and -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, the Netherlands
| | - Eibert R Heerdink
- Researchgroup Innovations in Pharmaceutical Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Jany Rademakers
- Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,CAPHRI, Care and Public Health Research Institute, Department of Family Medicine, Maastricht University, Maastricht, the Netherlands
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Ailabouni NJ, Reeve E, Helfrich CD, Hilmer SN, Wagenaar BH. Leveraging implementation science to increase the translation of deprescribing evidence into practice. Res Social Adm Pharm 2021; 18:2550-2555. [PMID: 34147372 DOI: 10.1016/j.sapharm.2021.05.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings.
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Affiliation(s)
- Nagham J Ailabouni
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia.
| | - Emily Reeve
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia; Dalhousie University and Nova Scotia Health Authority, Geriatric Medicine Research, Faculty of Medicine, And College of Pharmacy Halifax, Canada
| | - Christian D Helfrich
- University of Washington, School of Public Health, Veterans Administration Puget Sound Health Care System, Seattle, WA, USA
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
| | - Bradley H Wagenaar
- University of Washington, Department of Global Health, Seattle, WA, USA; University of Washington, Department of Epidemiology, Seattle, WA, USA
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10
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Zimmerman KM, Linsky AM. A narrative review of updates in deprescribing research. J Am Geriatr Soc 2021; 69:2619-2624. [PMID: 33991423 DOI: 10.1111/jgs.17273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES Deprescribing is a strategy intended to reduce harms associated with potentially inappropriate medications. Reflective of the growing interest in deprescribing, there has been an increase in related research to better understand the landscape, opportunities for improvement, how best to develop and implement interventions, and remaining knowledge gaps that can be addressed with additional study. DESIGN We conducted a narrative review of recent deprescribing literature. SETTING As part of the US Deprescribing Network's inaugural conference in October 2020, we presented a narrative review of recent deprescribing literature to an audience with a range of clinical and research expertise. PARTICIPANTS We searched four databases for English-language articles published between January 1, 2019 and August 31, 2020. MEASUREMENTS We evaluated titles, abstracts, and full-length manuscripts for relevance, novelty, rigor and variety of methods; we also aimed for broad representation of authors, institutions, and nations. RESULTS The initial search returned 199 citations, from which we reviewed 18 full-length manuscripts, selecting 10 articles to present. Salient themes included missed opportunities to deprescribe in potentially eligible patients, with variable impact of medication- and patient-level factors, along with differing perspectives and behaviors between geriatricians, internists, and cardiologists. Clinical, financial, and economic drivers were also evaluated. Finally, attention was given to issues applicable to deprescribing research, including difficulty recruiting trial participants, perspectives of investigators, and integration of findings into clinical practice. CONCLUSION This narrative review summarizes key advances in the field while also identifying priority areas for additional research.
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Affiliation(s)
- Kristin M Zimmerman
- Department of Pharmacotherapy & Outcomes Science, VCU School of Pharmacy, Richmond, Virginia, USA
| | - Amy M Linsky
- General Internal Medicine and Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA.,General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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11
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2019 Update. J Am Geriatr Soc 2021; 69:336-341. [PMID: 33438206 PMCID: PMC11057223 DOI: 10.1111/jgs.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Nagham J. Ailabouni
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Zachary A. Marcum
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L. Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
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Li-Wan-Po A, Peterson GM. Drug compliance and the Morisky Adherence Scale: An expression of concern and a warning. J Clin Pharm Ther 2020; 46:1-3. [PMID: 33285010 DOI: 10.1111/jcpt.13325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Every prescriber knows that patients often do not take their medicines as prescribed. Hippocrates, the wise man of Kos, knew over two millennia ago. Our objective is to comment on the types of studies aimed at understanding and optimizing drug usage and to draw attention to the need to seek approval before using or citing the Morisky adherence scale. COMMENT The study of prescribing and how patients use their medicines is important. As part of this effort, the results of investigations of how patients adhere to drug prescriptions can be informative. However, the results are meaningful only if the methods used for doing the measurements are valid and made explicit. We were surprised when a team of our authors were threatened with legal action for citing the Morisky Adherence Scale and explaining how some authors had obtained their adherence scores. Adherence studies are but one facet of the study of prescribing aimed at improving clinical outcomes. Other aspects include investigating the quality of prescribing, and how unnecessary medicines can be deprescribed to improve the quality of care and reduce the risk of adverse effects. WHAT IS NEW AND CONCLUSION The study of optimal prescribing is an important endeavour and adherence studies are but one aspect. We report that using and citing the Morisky Adherence scale in any detail is a risky business. Prior approval is required unless one is prepared to pay up, retrospectively. We require all authors to certify they have no conflicts of interest with respect to the scale.
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Affiliation(s)
| | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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Drug-Drug Interactions and Prescription Appropriateness in Patients with COVID-19: A Retrospective Analysis from a Reference Hospital in Northern Italy. Drugs Aging 2020; 37:925-933. [PMID: 33150470 PMCID: PMC7641655 DOI: 10.1007/s40266-020-00812-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
Background Patients hospitalised with severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2; coronavirus 2019 disease (COVID-19)] infection are frequently older with co-morbidities and receiving polypharmacy, all of which are known risk factors for drug–drug interactions (DDIs). The pharmacological burden may be further aggravated by the addition of treatments for COVID-19. Objective The aim of this study was to assess the risk of potential DDIs upon admission and during hospitalisation in patients with COVID-19 treated at our hospital. Methods We retrospectively analysed 502 patients with COVID-19 (mean age 61 ± 16 years, range 15–99) treated at our hospital with a proven diagnosis of SARS-CoV-2 infection hospitalised between 21 February and 30 April 2020 and treated with at least two drugs. Results Overall, 68% of our patients with COVID-19 were exposed to at least one potential DDI, and 55% were exposed to at least one potentially severe DDI. The proportion of patients experiencing potentially severe DDIs increased from 22% upon admission to 80% during hospitalisation. Furosemide, amiodarone and quetiapine were the main drivers of potentially severe DDIs upon admission, and hydroxychloroquine and particularly lopinavir/ritonavir were the main drivers during hospitalisation. The majority of potentially severe DDIs carried an increased risk of cardiotoxicity. No potentially severe DDIs were identified in relation to tocilizumab and remdesivir. Conclusions Among hospitalised patients with COVID-19, concomitant treatment with lopinavir/ritonavir and hydroxychloroquine led to a dramatic increase in the number of potentially severe DDIs. Given the high risk of cardiotoxicity and the scant and conflicting data concerning their efficacy in treating SARS-CoV-2 infection, the use of lopinavir/ritonavir and hydroxychloroquine in patients with COVID-19 with polypharmacy needs to be carefully considered.
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Baumgartner A, Kunkes T, Clark CM, Brady LA, Monte SV, Singh R, Wahler RG, Chen HYW. Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy. JMIR Hum Factors 2020; 7:e18103. [PMID: 32788157 PMCID: PMC7453327 DOI: 10.2196/18103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/12/2023] Open
Abstract
Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.
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Affiliation(s)
- Andrew Baumgartner
- Department of Family Medicine, University at Buffalo, State University of New York, Buffalo, NY, United States
| | - Taylor Kunkes
- Department of Industrial and Systems Engineering, School of Engineering and Applied Sciences, University at Buffalo, Buffalo, NY, United States
| | - Collin M Clark
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Laura A Brady
- Department of Family Medicine, Primary Care Research Institute, State University of New York at Buffalo, Buffalo, NY, United States
| | - Scott V Monte
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Ranjit Singh
- Department of Family Medicine, Primary Care Research Institute, State University of New York at Buffalo, Buffalo, NY, United States
| | - Robert G Wahler
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States
| | - Huei-Yen Winnie Chen
- Department of Industrial and Systems Engineering, School of Engineering and Applied Sciences, University at Buffalo, Buffalo, NY, United States
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