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Pavon JM, Sloane RJ, Colón-Emeric CS, Pieper CF, Schmader K, Gallagher D, Hastings SN. Central nervous system medication use around hospitalization. J Am Geriatr Soc 2024; 72:1707-1716. [PMID: 38600620 PMCID: PMC11187667 DOI: 10.1111/jgs.18915] [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: 01/02/2024] [Revised: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. METHODS Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). RESULTS Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. CONCLUSIONS CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.
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Affiliation(s)
- Juliessa M. Pavon
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Richard J. Sloane
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Cathleen S. Colón-Emeric
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Kenneth Schmader
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
| | - David Gallagher
- Department of Medicine/Division of General Internal Medicine/Hospital Medicine, Duke University, Durham, NC
| | - Susan N. Hastings
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, NC
- Health Services Research & Development, Durham Veterans Affairs Health Care System
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Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
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Koyama T, Iinuma S, Yamamoto M, Niimura T, Osaki Y, Nishimura S, Harada K, Zamami Y, Hagiya H. International Trends in Adverse Drug Event-Related Mortality from 2001 to 2019: An Analysis of the World Health Organization Mortality Database from 54 Countries. Drug Saf 2024; 47:237-249. [PMID: 38133735 DOI: 10.1007/s40264-023-01387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND OBJECTIVE Adverse drug events (ADEs) are becoming a significant public health issue. However, reports on ADE-related mortality are limited to national-level evaluations. Therefore, we aimed to reveal overall trends in ADE-related mortality across the 21st century on an international level. METHODS This observational study analysed long-term trends in ADE-related mortality rates from 2001 to 2019 using the World Health Organization Mortality Database. The rates were analysed according to sex, age and region. North America, Latin America and the Caribbean, Western Europe, Eastern Europe and Western Pacific regions were assessed. Fifty-four countries were included with four-character International Statistical Classification of Disease and Related Health Problems, Tenth Revision codes in the database, population data in the World Population Prospects 2019 report, mortality data in more than half of the study period, and high-quality or medium-quality death registration data. A locally weighted regression curve was used to show international trends in age-standardised rates. RESULTS The global ADE-related mortality rate per 100,000 population increased from 2.05 (95% confidence interval 0.92-3.18) in 2001 to 6.86 (95% confidence interval 5.76-7.95) in 2019. Mortality rates were higher among men than among women, especially in those aged 20-50 years. The population aged ≥ 75 years had higher ADE-related mortality rates than the younger population. North America had the highest mortality rate among the five regions. The global ADE-related mortality rate increased by approximately 3.3-fold from 2001 to 2019. CONCLUSIONS The burden of ADEs has increased internationally with rising mortality rates. Establishing pharmacovigilance systems can facilitate efforts to reduce ADE-related mortality rates globally.
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Affiliation(s)
- Toshihiro Koyama
- Department of Health Data Science, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Shunya Iinuma
- Department of Health Data Science, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Michio Yamamoto
- Graduate School of Human Sciences, Osaka University, Osaka, Japan
- RIKEN Center for Advanced Intelligence Project, Tokyo, Japan
| | - Takahiro Niimura
- Department of Clinical Pharmacology and Therapeutics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Yuka Osaki
- Department of Health Data Science, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Sayoko Nishimura
- Department of Health Data Science, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Ko Harada
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Hideharu Hagiya
- Department of Infectious Diseases, Okayama University Hospital, Okayama, 7008558, Japan.
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Pereira A, Ribeiro O, Veríssimo M. Predictors of older patients' willingness to have medications deprescribed: A cross-sectional study. Basic Clin Pharmacol Toxicol 2023; 133:703-717. [PMID: 37070165 DOI: 10.1111/bcpt.13874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Deprescribing is a complex process requiring a patient-centred approach. One frequently expressed deprescribing barrier is patients' attitudes and beliefs towards deprescribing. This study aimed to identify the predictors of patients' willingness to have medications deprescribed. METHODS A cross-sectional study was conducted with community-dwelling patients aged ≥65 who are taking at least one regular medication. Data collection included patients' demographic and clinical characteristics and the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics were used to present the patients' characteristics. Multiple binary logistic regression analysis was performed to identify the predictors of the patients' willingness to have medications deprescribed. RESULTS One hundred ninety-two participants (median age 72 years; 65.6% female) were included. Most (83.33%) were willing to have medications deprescribed, and the predictors were age (adjusted odds ratio [aOR] = 1.136; 95% CI 1.026, 1.258), female sex (aOR = 3.036; 95% CI 1.059, 8.708) and the rPATD concerns about stopping factor (aOR = 0.391; 95% CI 0.203, 0.754). CONCLUSIONS Most patients were willing to have their medications deprescribed if it is recommended by their doctors. Older age and female sex increased the odds of willingness to deprescribe; higher concerns about stopping medications decreased the odds. These findings suggest that addressing patients' concerns about stopping their medicines may contribute to deprescribing success.
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Affiliation(s)
- Anabela Pereira
- Department of Education and Psychology of the University of Aveiro, Campus Universitário de Santiago, University of Aveiro, Aveiro, Portugal
- Center for Health Technology and Services Research at the Associate Laboratory RISE, Health Research Network (CINTESIS@RISE), University of Aveiro, Campus Universitário de Santiago, Aveiro, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Oscar Ribeiro
- Department of Education and Psychology of the University of Aveiro, Campus Universitário de Santiago, University of Aveiro, Aveiro, Portugal
- Center for Health Technology and Services Research at the Associate Laboratory RISE, Health Research Network (CINTESIS@RISE), University of Aveiro, Campus Universitário de Santiago, Aveiro, Portugal
| | - Manuel Veríssimo
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Coimbra, Portugal
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Chan B, Isenor JE, Kennie-Kaulbach N. Categorization of deprescribing communication tools: A scoping review. Basic Clin Pharmacol Toxicol 2023; 133:640-652. [PMID: 37170716 DOI: 10.1111/bcpt.13886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Deprescribing can be beneficial to a wide variety of patients but is often not done due to barriers including lack of time and challenges starting conversations. OBJECTIVES This study aimed to identify and broadly categorize existing deprescribing communication tools for clinicians and patients. METHODS Our scoping review protocol was based on the Arksey and O'Malley methods and incorporated the Levac and Joanna Briggs Institute recommendations. EMBASE, CINAHL, PsycINFO, MEDLINE, and grey literature were searched, with two independent reviewers assessing eligibility. A backwards search of the texts chosen for full text screen was completed. Two reviewers independently completed data extraction using a pre-specified data collection form. FINDINGS Databases identified 1121 results, searching of grey literature identified 49 results, and backwards searching identified 1323 results. After screening, 32 resources were included which contained 40 unique tools. Most tools were Canadian and targeted adults over 65 years old living in the community. Most tools had not been tested in the intended patient audience or evaluated for effectiveness. DISCUSSION Deprescribing tools have been developed to facilitate conversations by providing structure, education, and decision-making approaches. More research is needed to test the effectiveness of existing tools.
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Affiliation(s)
- Bridgette Chan
- Dalhousie Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Jennifer E Isenor
- College of Pharmacy, Faculty of Health and Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Natalie Kennie-Kaulbach
- Practice Experience Program, College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
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Goh SSL, Lai PSM, Ramdzan SN, Tan KM. Weighing the necessities and concerns of deprescribing among older ambulatory patients and primary care trainees: a qualitative study. BMC PRIMARY CARE 2023; 24:136. [PMID: 37391698 PMCID: PMC10311750 DOI: 10.1186/s12875-023-02084-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 06/19/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Deprescribing can be a challenging and complex process, particularly for early career doctors such as primary care trainees. To date, there is limited data from patients' and doctors' perspectives regarding the deprescribing of medications in older persons, particularly from developing countries. This study aimed to explore the necessities and concerns of deprescribing in older persons among older ambulatory patients and primary care trainees. METHODS A qualitative study was conducted among patients and primary care trainees (known henceforth as doctors). Patients aged ≥ 60 years, having ≥ 1 chronic disease and prescribed ≥ 5 medications and could communicate in either English or Malay were recruited. Doctors and patients were purposively sampled based on their stage of training as family medicine specialists and ethnicity, respectively. All interviews were audio-recorded and transcribed verbatim. A thematic approach was used to analyse data. RESULTS Twenty-four in-depth interviews (IDIs) with patients and four focus group discussions (FGDs) with 23 doctors were conducted. Four themes emerged: understanding the concept of deprescribing, the necessity to perform deprescribing, concerns regarding deprescribing and factors influencing deprescribing. Patients were receptive to the idea of deprescribing when the term was explained to them, whilst doctors had a good understanding of deprescribing. Both patients and doctors would deprescribe when the necessity outweighed their concerns. Factors that influenced deprescribing were doctor-patient rapport, health literacy among patients, external influences from carers and social media, and system challenges. CONCLUSION Deprescribing was deemed necessary by both patients and doctors when there was a reason to do so. However, both doctors and patients were afraid to deprescribe as they 'didn't want to rock the boat'. Early-career doctors were reluctant to deprescribe as they felt compelled to continue medications that were initiated by another specialist. Doctors requested more training on how to deprescribe medications.
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Affiliation(s)
- Sheron Sir Loon Goh
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
- School of Medical and Life Sciences, Sunway University, Sunway City, Selangor, 47500, Malaysia.
| | - Siti Nurkamilla Ramdzan
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kit Mun Tan
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
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O'Donnell LK, Ibrahim K. Polypharmacy and deprescribing: challenging the old and embracing the new. BMC Geriatr 2022; 22:734. [PMID: 36068485 PMCID: PMC9450314 DOI: 10.1186/s12877-022-03408-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Ageing, Kolling Institute, Royal North Shore Hospital, Faculty of Medicine and Health, The University of Sydney, NSW, St Leonards, Australia.
| | - Kinda Ibrahim
- Academic Geriatric Medicine, Faculty of Medicine, University Hospital Southampton, University of Southampton, Southampton, UK. .,Applied Research Collaboration Wessex, The National Institute of Health and Care Research (NIHR), University of Southampton, Southampton, UK.
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Desai M, Park T. Deprescribing practices in Canada: A scoping review. Can Pharm J (Ott) 2022; 155:249-257. [PMID: 36081917 PMCID: PMC9445505 DOI: 10.1177/17151635221114114] [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: 07/09/2021] [Revised: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Background: Excessive and inappropriate use of medications, defined as polypharmacy, can increase the risk of adverse drug reactions while affecting patient adherence and quality of life. Therefore, optimizing pharmacotherapies through deprescribing practices plays a crucial role in managing chronic conditions, avoiding adverse effects and improving patient outcomes. The purpose of this study was to explore research initiatives surrounding deprescribing in Canada. Methods: A scoping review was conducted that involved a search of 6 databases. Studies that highlighted deprescribing interventions, experiences and other effects on Canadian populations were included. Results: Searches yielded 2327 citations, of which 31 were included in this review. Five major themes and ideas were identified: deprescribing targeted medications, financial effects of deprescribing, deprescribing in special populations, insight from health care providers and deprescribing frameworks. Conclusion: Deprescribing practices in Canada have shown a wide range of beneficial results across various health care settings, populations and medication classes and have the potential to reduce medication-related harm in all Canadian health care settings.
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Roux B, Rakheja B, Sirois C, Niquille A, Pétein C, Ouellet N, Spinewine A, Sibille FX, Laroche ML. Attitudes and beliefs of older adults and caregivers towards deprescribing in French-speaking countries: a multicenter cross-sectional study. Eur J Clin Pharmacol 2022; 78:1633-1646. [PMID: 35896803 DOI: 10.1007/s00228-022-03368-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Successful deprescribing requires understanding the attitudes of older adults and caregivers towards this process. This study aimed to capture these attitudes in four French-speaking countries and to investigate associated factors. METHODS A multicenter cross-sectional study was conducted by administrating the French version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in Belgium, Canada, France, and Switzerland. Community-dwelling or nursing home older adults ≥ 65 years taking ≥ 1 prescribed medications and caregivers of older adults with similar characteristics were included. Multivariate logistic regressions were carried out to examine factors associated with willingness to deprescribe. RESULTS A total of 367 older adults (79.3 ± 8.7 years, 63% community-dwelling, 54% ≥ 5 medications) and 255 unrelated caregivers (64.4 ± 12.6 years) of care recipients (83.4 ± 7.9 years, 52% community-dwelling, 69% ≥ 5 medications) answered the questionnaire. Among them, 87.5% older adults and 75.6% caregivers would be willing to stop medications if the physician said it was possible. Reluctance to stop a medication taken for a long time was expressed by 46% of both older adults and caregivers. A low score for the factor "concerns about stopping" (older adults: aOR: 0.21; 95% CI: 0.07-0.59), and a high score for the factor "involvement" (older adults: aOR: 2.66; 95% CI: 1.01-7.07; caregivers: aOR: 11.28; 95% CI: 1.48-85.91) were associated with willingness to deprescribe. CONCLUSIONS A significant proportion of older adults and caregivers of French-speaking countries are open to deprescribing. Despite this apparent willingness, deprescribing conversations in clinical practice remains marginal, emphasizing the importance of optimizing the integration of existing tools such as rPATD.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | | | - Caroline Sirois
- Faculty of Pharmacy, Laval University, Quebec, Canada.,Centre of Excellence On Aging of Quebec, Quebec, Canada.,Centre de recherche sur les soins et les Services de premieres lignes de l'Université Laval, Quebec, Canada
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Community Pharmacy, Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Catherine Pétein
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium
| | - Nicole Ouellet
- Department of Health, University of Quebec at Rimouski, Rimouski, Canada
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium.,Pharmacy Department, CHU UCL Namur, Yvoir, Belgium
| | - François-Xavier Sibille
- Department of Geriatric Medicine, CHU UCL Namur, Yvoir, Belgium.,Institute of Health and Society, UCLouvain, Brussels, Belgium
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France. .,Unité VIESANTE - UR 24134 (Vieillissement, Fragilité, Prévention, e-Santé), IFR OMEGA HEALTH, Université de Limoges, Limoges, France.
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Rakheja B, Sirois C, Ouellet N, Roux B, Laroche ML. Attitudes Toward Deprescribing in Older Adults and Caregivers: A Survey in Quebec, Canada. J Appl Gerontol 2022; 41:1376-1384. [PMID: 35246001 PMCID: PMC9024025 DOI: 10.1177/07334648211069553] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This study aimed to describe attitudes toward deprescribing among older adults and caregivers. We recruited 110 adults 65 years and above using at least one prescribed medication for at least 3 months, and 95 unrelated caregivers (18+) of older adults with such characteristics, who answered the validated French version of the revised Patients’ Attitudes Towards Deprescribing questionnaire. More older adults (84.5%) than caregivers (70.5%) (p = .007) would be willing to stop at least one medication if the doctor said it was possible. Conversely, 93.5% of older adults and 78.9% of caregivers were satisfied with the current medications taken (p = .0024). The results did not vary according to age, sex, number of medications taken, education level, or residency. Thus, older adults and caregivers are disposed to undertake deprescribing, regardless of sociodemographic characteristics. However, relying solely on satisfaction with current medications may not be sufficient to identify relevant deprescribing opportunities.
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Affiliation(s)
- Bianca Rakheja
- Faculté de Médecine, 12369Université Laval, Québec, Canada
| | - Caroline Sirois
- Faculté de Pharmacie, 4440Université Laval, Québec, Canada.,Centre d'excellence sur le Vieillissement de Québec, Québec, Canada.,VITAM, Centre de Recherche en Santé durable, Québec, Canada
| | - Nicole Ouellet
- Département des Sciences Infirmières, 14846Université du Québec à Rimouski, Rimouski, Canada
| | - Barbara Roux
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et d'information sur Les Médicaments, 36715CHU de Limoges, Limoges, France
| | - Marie-Laure Laroche
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et d'information sur Les Médicaments, 36715CHU de Limoges, Limoges, France.,Laboratoire Vie-Santé, Faculté de Médecine de Limoges, Limoges, France
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11
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Hollingsworth EK, Shah AS, Shotwell MS, Simmons SF, Vasilevskis EE. Older Patient and Surrogate Attitudes Toward Deprescribing During the Transition From Acute to Post-Acute Care. J Appl Gerontol 2022; 41:788-797. [PMID: 35164584 PMCID: PMC8867732 DOI: 10.1177/07334648211015756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Attitudes toward deprescribing among hospitalized older patients transitioning to post-acute care in the United States are less known. This study describes older patients' and their surrogate's attitudes using all items of the Patient Attitudes Toward Deprescribing (PATD) questionnaire and compares perceived pill burden to the actual count of total daily pills and potentially inappropriate medications (PIMs). Overall, 93% of participants were willing to deprescribe if their physician agreed. Compared to patients, surrogates had 64% reduced odds (95% CI: 0.18-0.74) of believing that all of the care recipient's medications were necessary and 61% reduced odds (95% CI: 0.17-0.88) of attributing cost as a factor in deprescribing. Perceptions of medication burden were associated with patients' total daily pills (median 16) and PIMS (median 7), yet 61% agreed that all their medicines were necessary. Patients and surrogates typically express a willingness to deprescribe but have differing perceptions of medication appropriateness.
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Affiliation(s)
| | | | | | - Sandra Faye Simmons
- Vanderbilt University Medical Center, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, USA
| | - Eduard Eric Vasilevskis
- Vanderbilt University Medical Center, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, USA
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12
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Ailabouni NJ, Rebecca Weir K, Reeve E, Turner JT, Wilson Norton J, Gray SL. Barriers and enablers of older adults initiating a deprescribing conversation. PATIENT EDUCATION AND COUNSELING 2022; 105:615-624. [PMID: 34183219 DOI: 10.1016/j.pec.2021.06.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/26/2021] [Accepted: 06/18/2021] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To examine older adults' perceptions and identify barriers and enablers to initiating a conversation about stopping medication(s) with their healthcare provider. METHODS We conducted one focus group (n = 3) and in-depth, face-to-face, individual interviews (n = 6) using an interview guide. Older adults aged ≥65 years in a retirement community who were taking ≥5 medications were recruited. Focus groups and interviews were audio-recorded and transcribed verbatim. Both a deductive analysis, informed by the Theoretical Domains Framework, and an inductive analysis were conducted. RESULTS Five themes and fourteen sub-themes were identified. Theme 1, 'older adult-related barriers', discusses limited or varying self-efficacy, past unsuccessful deprescribing experiences and limited familiarity with medications/deprescribing. Theme 2, 'provider-related barriers', discusses trust, short office visits, lack of communication and multiple providers. Theme 3, 'environmental/social-related barriers', involves limited availability of resources and access to telehealth/internet. The remaining themes (Themes 4-5) identified enablers including strategies to promote older adults' self-efficacy and improved healthcare communication. CONCLUSION Consumer-centric tools could improve older adults' self-efficacy to initiate deprescribing conversations. PRACTICE IMPLICATIONS Removing barriers and implementing enablers may empower older adults to initiate deprescribing conversations with providers to take fewer medications. Ultimately, this could be a catalyst for increased translation of deprescribing in practice.
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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, South Australia, Australia; School of Pharmacy, Plein Center for Geriatric Research, Education and Outreach, University of Washington, Seattle, WA, USA.
| | - Kristie Rebecca Weir
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, South Australia, Australia; University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Emily Reeve
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, South Australia, Australia; Dalhousie University and Nova Scotia Health Authority, Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Halifax, Canada
| | - Justin T Turner
- Institut Universitaire de Gériatrie de Montréal, Centre de Recherche, Montréal, Canada; University of Montreal, Faculty of Pharmacy, Montreal, Canada
| | - Jennifer Wilson Norton
- School of Pharmacy, Plein Center for Geriatric Research, Education and Outreach, University of Washington, Seattle, WA, USA
| | - Shelly L Gray
- School of Pharmacy, Plein Center for Geriatric Research, Education and Outreach, University of Washington, Seattle, WA, USA
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13
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Lai R, Withiel TD, Angelone M, Redpath C, O'Connor DW, Plakiotis C. Psychotropic medication deprescribing in residential aged care facilities: An exploratory study of the knowledge and attitudes of family members of residents with dementia. Australas J Ageing 2022; 41:e356-e363. [PMID: 35166431 PMCID: PMC10078740 DOI: 10.1111/ajag.13043] [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: 09/02/2021] [Revised: 12/29/2021] [Accepted: 01/07/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES General practitioners face many barriers to deprescribing psychotropic medications in people with dementia in nursing homes, including a lack of knowledge about their medication histories. This study explored the knowledge of family members about residents' medications and their willingness to support deprescribing. METHODS Sixty-six family members of residents from seven residential aged care facilities participated in this cross-sectional study. Participation involved nomination of recognised medications, rating their effectiveness and rating level of support for deprescribing. RESULTS Fifty-five per cent of medications were recognised by family members; significantly fewer psychotropics were recognised than non-psychotropic medications. Though rated as just as effective, support for deprescribing psychotropics was significantly higher. Most family members were agreeable to deprescribing with general practitioner support. CONCLUSIONS Although there is a gap in family members' knowledge about psychotropic medications, overall they are supportive of deprescribing. Findings emphasise the need for psychoeducation among family members. Providing family members with a list of prescribed medications, specifying the type of and reason for prescription and side effects of each, is recommended to facilitate their advocacy for deprescribing on behalf of nursing home residents.
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Affiliation(s)
- Rhoda Lai
- Monash Ageing Research Centre (MONARC), Monash University, Melbourne, Victoria, Australia
| | - Toni Dianne Withiel
- Monash Ageing Research Centre (MONARC), Monash University, Melbourne, Victoria, Australia.,Allied Health, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa Angelone
- Aged Mental Health Service, Monash Health, Melbourne, Victoria, Australia
| | - Cameron Redpath
- Monash Ageing Research Centre (MONARC), Monash University, Melbourne, Victoria, Australia
| | - Daniel W O'Connor
- Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Christos Plakiotis
- Monash Ageing Research Centre (MONARC), Monash University, Melbourne, Victoria, Australia.,Aged Mental Health Service, Monash Health, Melbourne, Victoria, Australia.,Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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14
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Thompson W, Jarbøl D, Nielsen JB, Haastrup P, Pedersen LB. GP preferences for discussing statin deprescribing: a discrete choice experiment. Fam Pract 2022; 39:26-31. [PMID: 34268565 DOI: 10.1093/fampra/cmab075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deprescribing (planned, supervised discontinuation) of statins may be considered in some older persons. This should be carefully discussed between patients and GPs. METHODS We examined GPs' preferences for discussing statin deprescribing by conducting a discrete choice experiment (DCE) sent to a stratified random sample of 500 Danish GPs. Attributes were discussion topics (goals of therapy, evidence on statin use in older persons, adverse effects, uncertainty), and levels were the depth of the discussion topics (none, brief, detailed). We used mixed logistic regression for analysis. RESULTS A total of 90 GPs (mean age 48, 54% female, mean 11 years in practice) completed the DCE. There was substantial variability in which topics GPs felt were most important to discuss; however, GPs generally preferred a brief discussion of topics to detailed ones. The most important discussion topic appeared to be goals of therapy. GPs felt a brief discussion of evidence was important but not a detailed one, while adverse effects and uncertainty were felt to be less important to discuss. CONCLUSION GPs prefer brief discussions on a range of topics when discussing statin deprescribing but have differing views on which topics are most important. For deprescribing communication tools to be useful to GPs in clinical practice, they may need to focus on brief coverage of the range of relevant topics. Future work should evaluate patient preferences, and opportunities for education and training for GPs on deprescribing communication.
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Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Hospital Pharmacy Fyn, Odense University Hospital, Odense, Denmark
| | - Dorte Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Peter Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Line Bjørnskov Pedersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Danish Centre for Health Economics (DaCHE), Department of Public Health, University of Southern Denmark, Odense, Denmark
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15
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Thompson AR, Kim CS, Kim GE, Keller MS, Marcum ZA, Brandt NJ. Challenges and Successes of Global Deprescribing Networks: A Qualitative Key Informant Study. J Gerontol Nurs 2022; 48:7-14. [PMID: 34978496 PMCID: PMC10115457 DOI: 10.3928/00989134-20211206-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The landscape of deprescribing has been rapidly evolving and expanding globally with the formation of regional and national deprescribing networks. The work of these networks is primarily focused on older adults and high-risk medications. The purpose of the current qualitative study is to describe successes and challenges of deprescribing from thought-leaders across the world. Fourteen key informant interviews were conducted from various disciplines, levels of experiences, and regions around the globe. From the interviews, six major themes across two domains were identified: (a) network structure, (b) public perception, (c) policy implications, (d) implementation, (e) challenges, and (f) recommendations. These domains, themes, and insight provided by deprescribing leaders contribute to the advancement of deprescribing networks as global efforts continue to focus on optimizing medication management. Collaboration among interprofessional team members will be critical to the expansion as well as sustainability of this important work. [Journal of Gerontological Nursing, 48(1), 7-14.].
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16
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Armistead LT, Sanders KA, Larson CK, Busby-Whitehead J, Ferreri SP. A-TAPER: A Framework for Deprescribing Medications effectively. Res Social Adm Pharm 2021; 18:3358-3361. [PMID: 34930683 DOI: 10.1016/j.sapharm.2021.11.013] [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: 06/16/2021] [Revised: 09/30/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
Inappropriate medication use creates avoidable safety issues for older adults. Deprescribing medications that are high risk and/or of minimal benefit is important for reducing morbidity and adverse effects, especially in this population. A variety of deprescribing resources and algorithms are available, but a singular framework to effectively approach and implement the deprescribing of unnecessary medications in practice does not exist. An interprofessional team of pharmacists, geriatricians, and researchers developed a framework to guide providers in deprescribing medications. This framework is represented by the acronym A-TAPER, which stands for Assess medication use, Talk about risks versus benefits, select Alternatives, Plan next steps, Engage patient, and Reduce dose. Within this framework, comprehensive, medication-specific deprescribing toolkits can be created.
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Affiliation(s)
- L T Armistead
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
| | - K A Sanders
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
| | - C K Larson
- UNC School of Medicine, Division of Geriatric Medicine, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA.
| | - J Busby-Whitehead
- UNC School of Medicine, Division of Geriatric Medicine, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA; UNC Center for Aging and Health, 5003 Old Clinic Bldg. Chapel Hill, NC, 27599-7550, USA.
| | - S P Ferreri
- UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599-7574, USA.
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17
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Hahn EE, Munoz-Plaza CE, Lee EA, Luong TQ, Mittman BS, Kanter MH, Singh H, Danforth KN. Patient and Physician Perspectives of Deprescribing Potentially Inappropriate Medications in Older Adults with a History of Falls: a Qualitative Study. J Gen Intern Med 2021; 36:3015-3022. [PMID: 33469744 PMCID: PMC8481353 DOI: 10.1007/s11606-020-06493-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND High-risk medications pose serious safety risks to older adults, including increasing the risk of falls. Deprescribing potentially inappropriate medications (PIMs) in older adults who have experienced a fall is a key element of fall reduction strategies. However, continued use of PIMs in older adults is common, and clinicians may face substantial deprescribing barriers. OBJECTIVE Explore patient and clinician experiences with and perceptions of deprescribing PIMs in patients with a history of falls. DESIGN We led guided patient feedback sessions to explore deprescribing scenarios with patient stakeholders and conducted semi-structured interviews with primary care physicians (PCPs) to explore knowledge and awareness of fall risk guidelines, deprescribing experiences, and barriers and facilitators to deprescribing. PARTICIPANTS PCPs from Kaiser Permanente Southern California (KPSC) and patient members of the KPSC Regional Patient Advisory Committee. APPROACH We used maximum variation sampling to identify PCPs with patients who had a fall, then categorized the resulting PIM dispense distribution for those patients into high and low frequency. We analyzed the data using a hybrid deductive-inductive approach. Coders applied initial deductively derived codes to the data, simultaneously using an open-code inductive approach to capture emergent themes. KEY RESULTS Physicians perceived deprescribing discussions as potentially contentious, even among patients with falls. Physicians reported varying comfort levels with deprescribing strategies: some felt that the conversations might be better suited to others (e.g., pharmacists), while others had well-planned negotiation strategies. Patients reported lack of clarity as to the reasons and goals of deprescribing and poor understanding of the seriousness of falls. CONCLUSIONS Our study suggests that key barriers to deprescribing include PCP trepidation about raising a contentious topic and insufficient patient awareness of the potential seriousness of falls. Findings suggest the need for multifaceted, multilevel deprescribing approaches with clinician training strategies, patient educational resources, and a focus on building trusting patient-clinician relationships.
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Corrine E Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Eric Anthony Lee
- Division of Internal Medicine, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA, USA
| | - Tiffany Q Luong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Brian S Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael H Kanter
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kim N Danforth
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.,RTI International, Research Triangle Park, NC, USA
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18
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Ribeiro PRDS, Schlindwein AD. Benzodiazepine deprescription strategies in chronic users: a systematic review. Fam Pract 2021; 38:684-693. [PMID: 33907803 DOI: 10.1093/fampra/cmab017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As long-term use of benzodiazepines increases, adverse effects also become more frequent, especially in elderly adults. Due the potential of causing dependence, poor patient adherence and a lack of awareness of side effects, deprescription is challenging. OBJECTIVE This study aimed to identify what are the effective approaches to motivate and promote deprescription of benzodiazepines. METHODS We used MeSH terms to search in five databases that were MEDLINE, Cochrane CENTRAL, LILACS, SCIELO and Science Direct. Then, we selected articles accordingly to inclusion and exclusion criteria. Risk of bias assessment for randomized controlled trials and prospective interventional studies was made using RoB 2.0 and ROBINS-I tools, respectively. For cohort studies, we used the clarity group by McMaster University tool. RESULTS Database search retrieved 412 results, and 11 studies were selected for analysis. Interventions focusing on patient education to improve community awareness about deprescription presented better discontinuation rates and more potential on motivating discussions about deprescribing with physicians. Interventions based on counselling by different health professionals were not well evaluated as they presented four of six studies as high, serious or critical risk of bias. CONCLUSIONS Although the comparison of different strategies was impaired by the high risk of bias in some studies, patient education focused interventions presented good results. Future studies should consider doing a follow-up of 6 months or longer with evaluation of withdrawal symptoms and sleep patterns, inclusion of young adults on the sample and some form of cognitive evaluation that might influence the results of the intervention.
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Affiliation(s)
| | - Aline Daiane Schlindwein
- Science and Technology Division, Directorate of Permanent Health Education, State Secretariat of Health of Santa Catarina, Brazil
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19
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Forest E, Ireland M, Yakandawala U, Cavett T, Raman-Wilms L, Falk J, McMillan D, Linthorst R, Kosowan L, Labine L, Leong C. Patient values and preferences on polypharmacy and deprescribing: a scoping review. Int J Clin Pharm 2021; 43:1461-1499. [PMID: 34550540 DOI: 10.1007/s11096-021-01328-w] [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: 07/23/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022]
Abstract
Background Understanding how patient values and preferences towards polypharmacy and deprescribing have been studied is important to gain insight on current knowledge in this area and to identify knowledge gaps. Aim To describe methods and outcomes for studying patient values and preferences towards polypharmacy and deprescribing, and to identify gaps in the existing literature. Method A scoping review was conducted on English-language studies that examined patient preferences and values related to polypharmacy and/or deprescribing among community-dwelling adults. MEDLINE, Embase, PubMed, PsycINFO, EconLit, Social Science Citation Index, Science Citation Index Expanded, International Pharmaceutical Abstracts, and CINAHL/AgeLine were searched. Results Thirty articles were included. Surveys (n = 17, 56.7%), interviews/focus groups (n = 9, 30.0%), and mixed methods (n = 3, 10.0%), were commonly used methods. Patients Attitudes Towards Deprescribing (PATD) was the most common tool used (n = 9, 30.0%). Twelve themes related to attitudes, social pressure, and control of polypharmacy/deprescribing were identified. The most frequently-encountered themes included desire or willingness to reduce medication load and influence of healthcare provider on medication use. Conclusion PATD was commonly used to assess preferences and values towards polypharmacy and limited knowledge on patient-important outcomes were addressed. Future research should focus on shared decision-making and communicating risk versus benefit of medications.
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Affiliation(s)
- Evan Forest
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Melissa Ireland
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Uma Yakandawala
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Teresa Cavett
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Jamie Falk
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Diana McMillan
- College of Nursing, University of Manitoba, Winnipeg, MB, Canada
| | - Rhys Linthorst
- Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada
| | - Leanne Kosowan
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lisa Labine
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Christine Leong
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada.
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20
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Arnoldussen DL, Keijsers K, Drinkwaard J, Knol W, van Marum RJ. Older Patients' Perceptions of Medicines and Willingness to Deprescribe. Sr Care Pharm 2021; 36:444-454. [PMID: 34452654 DOI: 10.4140/tcp.n.2021.444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction Major barriers in deprescribing are the ambivalence of patients, resistance to change, and poor acceptance of alternative treatments. Objective To investigate older patients' beliefs, understanding and knowledge, satisfaction with medicine use, health outcome priorities, their attitude toward deprescribing, and to identify associated patient factors. Methods This multi-center cross-sectional, semistructured survey study involved older outpatients (70 years of age and older) with polypharmacy. The survey comprised three validated questionnaires: Beliefs about Medicines Questionnaire, Patients' Attitudes Towards Deprescribing questionnaire, and the Health Outcome Prioritization tool, with additional questions about understanding and satisfaction. The association between questionnaire outcomes and patient characteristics was investigated. Results Fifty participants were included; they used an average of 9 (+/- SD 2.7) medicines. For most participants (82%), the necessity of using medicines outweighed their concerns. Participants could name 35% of their medicines and 43% of the indications. Overall, 76% were satisfied with the effect of their medicines, but 94% would be willing to stop their medication if advised by their doctor. Maintaining independence (46%) and reducing pain (31%) were the most important health outcome priorities reported by the patients; staying alive had the lowest priority (51%). Participants with higher levels of educational attainment had better knowledge and had more concerns about harmful effects. Conclusions Patients are open to deprescribing but would probably not initiate the conversation themselves because they are generally very satisfied with their medicines. Knowledge about their medicines and their indications is poor. If doctors initiate deprescribing, patients are probably willing to follow their advice. Patients' life priorities should be discussed in deprescribing conversations.
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21
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Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. LANCET HEALTHY LONGEVITY 2021; 2:e290-e300. [DOI: 10.1016/s2666-7568(21)00054-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 01/27/2023]
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de Juan-Roldán JI, Gavilán-Moral E, Leiva-Fernández F, García-Ruiz AJ. [Validation into Spanish of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire to assess patients' attitudes towards deprescribing. Research protocol]. Rev Esp Geriatr Gerontol 2021; 56:218-224. [PMID: 33892991 DOI: 10.1016/j.regg.2021.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/15/2020] [Accepted: 02/26/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND OBJECTIVE Polypharmacy has become a priority public health problem in developed countries. In response to its approach, deprescription stands out. Its success will depend largely on the attitudes and beliefs of patients towards the number of drugs they are taking and their willingness to initiate a process of deprescription. To explore these factors, researchers have developed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire, originally in English. The objective of this study is the validation into Spanish of rPATD questionnaire, both older adults and caregivers versions. MATERIAL AND METHODS A first qualitative validation phase and a second phase of analysis of its psychometric characteristics will be carried out through an observational descriptive study of validation of a measurement instrument. One hundred and twenty subjects (polymedicated older adults and caregivers) from three health centers will be selected by consecutive sampling. The questionnaire will be provided and clinical and sociodemographic data will be collected. Feasibility, reliability (through internal consistency and intraobserver reliability) and validity (apparent, construct and criterion) of the questionnaire will be evaluated. EXPECTED RESULTS It is expected to obtain a questionnaire that will serve as a tool for the clinician to identify patients with a favorable predisposition to deprescription and that will allow to contribute the patient's perspective to this process. CONCLUSION The use of the rPATD questionnaire, alone or integrated into other more complex interventions, may lead to an improvement in the quality of care for the polymedicated patients.
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Affiliation(s)
- José Ignacio de Juan-Roldán
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, Málaga, España; Laboratorio de Prácticas Innovadoras en Polimedicación y Salud, Cáceres, España.
| | - Enrique Gavilán-Moral
- Laboratorio de Prácticas Innovadoras en Polimedicación y Salud, Cáceres, España; Consultorio Rural Mirabel, Cáceres, España
| | - Francisca Leiva-Fernández
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria de Distrito de Atención Primaria Málaga/Guadalhorce, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), REDISSEC ISCIII, Universidad de Málaga, Málaga, España
| | - Antonio J García-Ruiz
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, Málaga, España
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23
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Ng B, Duong M, Lo S, Le Couteur D, Hilmer S. Deprescribing perceptions and practice: Reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module. Res Social Adm Pharm 2021; 17:1997-2005. [PMID: 33773940 DOI: 10.1016/j.sapharm.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing. OBJECTIVES 1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students. METHODS A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module. RESULTS Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions. CONCLUSIONS Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.
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Affiliation(s)
- Brendan Ng
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia; Capital and Coast District Health Board, Wellington, New Zealand.
| | - Mai Duong
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Sarita Lo
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - David Le Couteur
- University of Sydney and Concord Hospital, Centre for Education and Research on Ageing, Concord, New South Wales, Australia
| | - Sarah Hilmer
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
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Kardas P, Urbański F, Lichwierowicz A, Chudzyńska E, Czech M, Makowska K, Kardas G. The Prevalence of Selected Potential Drug-Drug Interactions of Analgesic Drugs and Possible Methods of Preventing Them: Lessons Learned From the Analysis of the Real-World National Database of 38 Million Citizens of Poland. Front Pharmacol 2021; 11:607852. [PMID: 33536918 PMCID: PMC7849760 DOI: 10.3389/fphar.2020.607852] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/07/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction: Drug-drug interactions may lead to poor health outcomes, as well as increased costs and utilization of healthcare services. Unfortunately, real-world data continuously prove high prevalence of potential drug-drug interactions (pDDIs) worldwide. Among identified drivers, ageing, multimorbidity and polypharmacy play a very important role. With these factors being widespread, the need for implementation of strategies minimizing the burden of pDDIs becomes an urgency. This, however, requires a better understanding of the prevalence of pDDIs and the underlying causative factors. Aim of study: To assess the real-world prevalence of pDDIs and its characteristics in the general population of Poland, using analgesic drugs as a model, and to find out whether pDDIs are caused by prescribing coming from the very same prescribers (co-prescribing). Methods: A retrospective analysis of the 2018 dispensation data of the National Health Fund (NHF) - the only Polish public healthcare payer organization with nationwide coverage. We searched for selected pDDIs of non-steroidal anti-inflammatory drugs (NSAIDs) with antihypertensives, other NSAIDs (double use), oral glucocorticoids, oral anticoagulants, selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and antiplatelet drugs; as well as opioides with SSRIs, SNRIs, gabapentinoids, and benzodiazepines. A pDDI was deemed present if two drugs standing in a possible conflict were dispensed within the same calendar month. Results: Out of 38.4 million citizens of Poland, 23.3 million were dispensed prescribed drugs reimbursed by NHF in 2018. In this cohort, we have identified 2,485,787 cases of analgesic drug pDDIs, corresponding with 6.47% of the Polish population. Out of these, the most prevalent pDDI was caused by “NSAIDs + antihypertensives” (1,583,575 cases, i.e., 4.12% of the Polish population), followed by “NSAIDs + NSAIDs” (538,640, 1.40%) and “NSAIDs + glucocorticoids” (213,504, 0.56%). The most persistent pDDIs among those studied were caused by “Opioids + Gabapentinoids” (2.19, 95%CI: 2.16–2.22 months). On average, 76.63% of all cases of pDDIs were caused by drugs prescribed by the very same prescribers. Conclusion: Based on high-quality, nationwide data, we have found a high prevalence of analgesic drugs-related pDDIs in Poland. Over ¾ of the identified pDDIs were caused by co-prescribing, i.e., prescriptions issued by the same prescribers. The significance of the problem, illustrated with our findings on analgesic drugs-related pDDIs in Poland, deserves much more scientific and policymaker attention.
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Affiliation(s)
- Przemysław Kardas
- Department of Family Medicine, Medical University of Lodz, Łódź, Poland
| | | | | | | | - Marcin Czech
- Department of Pharmacoeconomics, Institute of Mother and Child, Warsaw, Poland
| | | | - Grzegorz Kardas
- Department of Internal Diseases, Asthma and Allergy, Medical University of Lodz, Łódź, Poland
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Dharmarajan TS. The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing. J Am Med Dir Assoc 2020; 22:15-22. [PMID: 33321078 DOI: 10.1016/j.jamda.2020.09.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 02/07/2023]
Abstract
Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided. The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth. Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using "on-demand" therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted. PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.
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Affiliation(s)
- Thiruvinvamalai S Dharmarajan
- Department of Medicine, Geriatric Medicine, Geriatric Medicine Fellowship Program, Montefiore Medical Center, Wakefield Campus, Bronx, NY, USA; Albert Einstein College of Medicine, Bronx, NY, USA.
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26
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Ikeji C, Williams A, Hennawi G, Brandt NJ. Patient and Provider Perspectives on Deprescribing Proton Pump Inhibitors. J Gerontol Nurs 2020; 45:9-17. [PMID: 31560071 DOI: 10.3928/00989134-20190912-03] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9-17.].
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Roux B, Sirois C, Simard M, Gagnon ME, Laroche ML. Potentially inappropriate medications in older adults: a population-based cohort study. Fam Pract 2020; 37:173-179. [PMID: 31602472 DOI: 10.1093/fampra/cmz060] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Non-optimal medication use among older adults is a public health concern. A concrete picture of potentially inappropriate medication (PIM) use is imperative to ensure optimal medication use. OBJECTIVE To assess the prevalence of PIMs in community-dwelling older adults and identify associated factors. METHODS A retrospective population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System (QICDSS). The QICDSS includes data on drug claims for community-dwelling older adults with chronic diseases or at risk of developing chronic diseases aged ≥65 years who are insured by the public drug insurance plan. Individuals aged ≥66 years who were continuously insured with the public drug plan between 1 April 2014 and 31 March 2016 were included. PIMs were defined using the 2015 Beers criteria. We conducted multivariate robust Poisson regression analyses to explore factors associated with PIM use. RESULTS A total of 1 105 295 individuals were included. Of these, 48.3% were prescribed at least one PIM. The most prevalent PIMs were benzodiazepines (25.7%), proton-pump inhibitors (21.3%), antipsychotics (5.6%), antidepressants (5.0%) and long-duration sulfonylureas (3.3%). Factors associated with PIM exposure included being a woman [rate ratio (RR): 1.20; 95% confidence interval (CI): 1.20-1.21], increased number of medications and having a high number of chronic diseases, especially mental disorders (RR: 1.50; 95% CI: 1.49-1.51). CONCLUSION Almost one out of two community-dwelling older adults use a PIM. It is imperative to reduce the use of PIMs, by limiting their prescription and by promoting their deprescribing, which necessitates not only the active involvement of prescribers but also patients.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada
| | - Caroline Sirois
- Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Centre of Excellence on Aging of Quebec, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada
| | - Marc Simard
- Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Eve Gagnon
- Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
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Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M, Gnjidic D. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol 2020; 13:233-245. [PMID: 32056451 DOI: 10.1080/17512433.2020.1730812] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.
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Affiliation(s)
- Mouna Sawan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, St Leonards, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Justin Turner
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, Australia
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Pickering AN, Hamm ME, Dawdani A, Hanlon JT, Thorpe CT, Gellad WF, Radomski TR. Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study. J Am Geriatr Soc 2020; 68:746-753. [PMID: 32067226 DOI: 10.1111/jgs.16370] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Shared decision making is essential to deprescribing unnecessary or harmful medications in older adults, yet patients' and caregivers' perspectives on medication value and how this affects their willingness to discontinue a medication are poorly understood. We sought to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers. DESIGN Qualitative study using focus groups conducted in September and October 2018. SETTING Participants from the Pepper Geriatric Research Registry (patients) and the Pitt+Me Registry (caregivers) maintained by the University of Pittsburgh. PARTICIPANTS Six focus groups of community-dwelling adults aged 65 years or older, or their caregivers, prescribed five or more medications in the preceding 12 months. MEASUREMENTS We sought to identify (1) general views on medication value and what makes medication worth taking; (2) how specific features such as cost or side effects impact perceived value; and (3) reactions to clinical scenarios related to deprescribing. RESULTS We identified four themes. Perceived effectiveness was the primary factor that caused participants to consider a medication to be of high value. Participants considered a medication to be of low value if it adversely affected quality of life. Participants also cited cost when determining value, especially if it resulted in material sacrifices. Participants valued medications prescribed by providers with whom they had good relationships rather than valuing level of training. When presented with clinical scenarios, participants ably weighed these factors when determining the value of a medication and indicated whether they would adhere to a deprescribing recommendation. CONCLUSION We identified that perceived effectiveness, adverse effects on quality of life, cost, and a strong relationship with the prescriber influenced patients' and caregivers' views on medication value. These findings will enable prescribers to engage older patients in shared decision making when deprescribing unnecessary medications and will allow health systems to incorporate patient-centered assessment of value into systems-based deprescribing interventions. J Am Geriatr Soc 68:746-753, 2020.
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Affiliation(s)
- Aimee N Pickering
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Megan E Hamm
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alicia Dawdani
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Thomas R Radomski
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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30
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Roux B, Sirois C, Simard M, Gagnon ME, Laroche ML. One-year persistence of potentially inappropriate medication use in older adults: A population-based study. Br J Clin Pharmacol 2020; 86:1062-1080. [PMID: 31916266 DOI: 10.1111/bcp.14214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada. METHODS A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM. RESULTS In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases. CONCLUSIONS One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Quebec National Institute of Public Health, Quebec, Canada
| | - Caroline Sirois
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Centre of Excellence on Aging of Quebec, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada
| | - Marc Simard
- Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Eve Gagnon
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
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31
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Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc 2019; 21:355-360. [PMID: 31672564 DOI: 10.1016/j.jamda.2019.08.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/11/2019] [Accepted: 08/30/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process. DESIGN As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process. RESULTS Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success. CONCLUSIONS AND IMPLICATIONS Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.
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Self-reported barriers to medication use in older women: Findings from the Women's Health Initiative. J Am Pharm Assoc (2003) 2019; 59:842-847. [PMID: 31405806 DOI: 10.1016/j.japh.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 05/30/2019] [Accepted: 07/03/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To describe the prevalence of, types of, and characteristics associated with self-reporting multiple (≥ 2) barriers to medication use in older women using long-term cardiovascular and oral hypoglycemic medications. METHODS This cross-sectional study set at the Women's Health Initiative during 2005-2010 included women who were using any chronic medication from 3 target classes (i.e., antilipemics, antihypertensives, oral hypoglycemics) for at least 1 month and who had answered questions about barriers to medication use at year 4 (2009) of the study period (N = 59,054). Measurements included common self-reported barriers to medication use, and sociodemographic, health characteristic, medication use, and access to care variables were evaluated. Multivariable logistic regression models were used to examine associations between participant characteristics and barriers to medication use. RESULTS Among the participants, 47,846 (81%) reported no barriers, 7105 (12%) reported 1 barrier, and 4103 (6.9%) reported 2 or more barriers to medication use. The most common barriers reported were having concerns about adverse effects, not liking to take medications, and medications costing too much. Several characteristics were found to be associated with reporting 2 or more barriers in multivariable modeling, including demographic (e.g., lower age, black race, Hispanic ethnicity) and health or medication (e.g., lower quality of life, lower physical function, higher number of concurrent medications) characteristics. CONCLUSION Among older women using chronic cardiovascular and oral hypoglycemic medications, approximately 20% reported at least 1 barrier to medication use, with 7% of women reporting multiple barriers. Pharmacists should prioritize identifying barriers to medication use in older women using chronic medications to improve patient care.
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Abstract
PURPOSE OF REVIEW A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines. RECENT FINDINGS Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med 2018; 178:1673-1680. [PMID: 30326004 PMCID: PMC6583614 DOI: 10.1001/jamainternmed.2018.4720] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Use of harmful and/or unnecessary medications in older adults is prevalent. This can lead to avoidable harms such as adverse drug reactions, falls, hospitalization, and mortality. Primary care physicians report that patient resistance to discontinuing medication use is a significant barrier to deprescribing. OBJECTIVE To describe the attitudes of older adults toward deprescribing and to determine whether individual characteristics are associated with these attitudes. DESIGN, SETTING, AND PARTICIPANTS For this population-based survey study of US Medicare beneficiaries 65 years and older, data were obtained from the Medication Attitudes module fielded through in-person interviews in round 6 of the National Health and Aging Trends Study (weighted response rate of round 6 was 88.5%). The questions in this module were drawn from the Patients' Attitudes Towards Deprescribing questionnaire and its revised version. The Medication Attitudes module was fielded to a random one-third (n = 2124) of the National Health and Aging Trends Study participants (weighted response rate of this module was 94.8%). MAIN OUTCOMES AND MEASURES Responses to 2 statements ("If my doctor said it was possible, I would be willing to stop one or more of my regular medicines" and "I would like to reduce the number of medicines I am taking") were the main outcomes of interest. RESULTS Of the 1981 Medicare beneficiaries included in the study, 1149 (55.2%, weighted) were women, and the majority (n = 715 [54.6%, weighted]) were 65 to 74 years old. A total of 1752 (92.0%, weighted) older adults reported being willing to stop taking 1 or more of their medicines if their physician said it was possible, and 1241 (66.6%, weighted) older adults wanted to reduce the number of medicines that they were taking. Older adults taking 6 or more medications had greater odds than those taking fewer than 6 medications of being willing to stop taking 1 or more of their medicines (adjusted odds ratio, 2.90; 95% CI, 1.74-4.82) and wanting to reduce the number of medicines that they were taking (adjusted odds ratio, 2.31; 95% CI, 1.71-3.13). CONCLUSIONS AND RELEVANCE Physicians considering deprescribing as part of comprehensive, patient-centered care should be reassured that a majority of older Americans are open to having 1 or more of their medicines deprescribed if their physician says it is possible, and more than two-thirds want to reduce the number of medicines that they are taking.
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Affiliation(s)
- Emily Reeve
- National Health and Medical Research Council Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia.,Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maureen Skehan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora.,Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | - Sarah N Hilmer
- National Health and Medical Research Council Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia.,Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Turner JP, Richard C, Lussier MT, Lavoie ME, Farrell B, Roberge D, Tannenbaum C. Deprescribing conversations: a closer look at prescriber-patient communication. Ther Adv Drug Saf 2018; 9:687-698. [PMID: 30546863 DOI: 10.1177/2042098618804490] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/28/2018] [Indexed: 12/15/2022] Open
Abstract
Background Little is known about the initiation, style and content of patient and healthcare provider communication around deprescribing. We report the findings from a content analysis of audio-recorded discussions of proton pump inhibitor (PPI) and benzodiazepine deprescribing in primary care. Methods Participants were healthcare providers (n = 13) from primary care practices (n = 3) and patients aged ⩾65 (n = 24) who were chronic users of PPIs or benzodiazepines. The EMPOWER educational brochures were distributed prior to (n = 15) or after (n = 9) the patient's usual healthcare provider appointment. Conversations were audio-recorded and coded using MEDICODE to analyze who initiated different themes, whether they followed a monologue or dialogue style, and to what extent the thematic content addressed issues pertaining to: 'dosage/instructions,' 'medication action and efficacy,' 'risk/adverse effects,' 'attitudes/emotions,' 'adherence' and 'follow up.' Descriptive analysis of the conversations was performed with comparison between patients who received the EMPOWER brochure before or after their appointments. Results Patients were mostly women (67%) with a mean age of 74 ± 6 years. For PPI users, prior education resulted in a greater proportion of themes initiated by patients (44% versus 17%) and maintaining dialogue-style conversations (48% versus 28%). Among benzodiazepine users, conversation initiation (52% versus 47%) and conversation style was similar between both groups. The content of deprescribing conversations for PPIs revealed that patients and their healthcare providers focused less on 'dosage/instructions,' and more on the 'medication action and efficacy' and the necessity for 'follow up.' Conversations about stopping benzodiazepines were more likely to stagnate on the 'if' rather than the 'how.' Conclusion The initiation, style and content of the conversations varied between PPI and benzodiazepine users, suggesting that healthcare providers will need to tailor deprescribing conversations accordingly.
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Affiliation(s)
- Justin P Turner
- Facultés de Pharmacie, Université de Montréal Research Center of Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | - Claude Richard
- Équipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Marie-Thérèse Lussier
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, CanadaÉquipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Marie-Eve Lavoie
- Équipe de Recherche en Soins de Première Ligne, Centre Intégré de Santé et de Services Sociaux de Laval, Québec, Canada
| | - Barbara Farrell
- Geriatric Day Hospital, Bruyère Continuing Care, Bruyère Research Institute and CT Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Cara Tannenbaum
- Facultés de Médecine et de Pharmacie, Université de MontréalResearch Center of Institut Universitaire de Gériatrie de Montréal, Québec, Canada
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Turner JP, Currie J, Trimble J, Tannenbaum C. Strategies to promote public engagement around deprescribing. Ther Adv Drug Saf 2018; 9:653-665. [PMID: 30479740 DOI: 10.1177/2042098618794165] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/21/2018] [Indexed: 11/15/2022] Open
Abstract
Many seniors remain unaware that certain medications may be harmful, despite high rates of polypharmacy and inappropriate medication use among community-dwelling older adults. Patient education is an effective method for reducing the use of inappropriate medications. Increasing public awareness and engagement is essential for promoting shared decision-making to deprescribe. The Canadian Deprescribing Network was created to address the lack of a systematic pan-Canadian initiative to implement deprescribing among older Canadians. The Canadian Deprescribing Network deliberately included patient advocates in its organization from the outset, in order to ensure a key strategic focus on public awareness and education. In this paper, we present the processes and activities rolled out by the Canadian Deprescribing Network as a blueprint model for engaging the public on deprescribing. Embedded within the structure of the network, the subcommittee on public awareness and engagement implements an action plan that includes needs assessments, population surveys, focus groups, deprescribing fairs, national stakeholders' meetings, public lectures and monthly exchanges with community champions and seniors' organizations. Educational materials and online media have been developed based on the answers to the questions: what information do seniors need about deprescribing? who should this information be delivered to? who needs to deliver the message? and how should seniors be engaged in deprescribing? In conjunction with seniors' organizations, members of the Network have iteratively refined key deprescribing messages, disseminated information about deprescribing, engaged the press and created a grass roots-driven public awareness and education campaign across Canada. Over 3000 seniors and seniors' organizations are involved, with over 25,000 educational tools being distributed across the country.
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Affiliation(s)
- Justin P Turner
- Centre de recherche Institut universitaire de gériatrie de Montréal 4545 chemin Queen Mary, Montreal, CANADA, H3W 1W4
| | - Janet Currie
- Interdisciplinary Studies Graduate Program and Applied Science/School of Nursing, University of British Columbia, British Columbia, Canada
| | - Johanna Trimble
- Patients for Patient Safety Canada, BC Patient Voices Network, Community Engagement Advisory Network (Vancouver Coastal Health Authority), British Columbia, Canada
| | - Cara Tannenbaum
- Facultés de Médecine et de Pharmacie, Université de Montréal; Research Center of Institut Universitaire de Gériatrie de Montréal, Québec, Canada
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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Wilson MG, Lee TC, Hass A, Tannenbaum C, McDonald EG. EMPOWERing Hospitalized Older Adults to Deprescribe Sedative Hypnotics: A Pilot Study. J Am Geriatr Soc 2018; 66:1186-1189. [DOI: 10.1111/jgs.15300] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Todd C. Lee
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Aaron Hass
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Cara Tannenbaum
- Division of Geriatrics, Department of Medicine; Université de Montréal; Montréal Quebec Canada
| | - Emily G. McDonald
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
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