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Vasilevskis EE, Trumbo SP, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Simmons SF. Medication Discrepancies among Older Hospitalized Adults Discharged from Post-Acute Care Facilities to Home. J Am Med Dir Assoc 2024; 25:105017. [PMID: 38754476 DOI: 10.1016/j.jamda.2024.105017] [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: 12/20/2023] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The epidemiology of medication discrepancies during transitions from post-acute care (PAC) to home is poorly described. We sought to describe the frequency and types of medication discrepancies among hospitalized older adults transitioning from PAC to home. DESIGN A nested cohort analysis. SETTING AND PARTICIPANTS Included participants enrolled in a patient-centered deprescribing trial, for patients (aged ≥50 years and taking at least 5 medications) transitioning from one of 22 PACs to home. METHODS We assessed demographic and medication measures at the initial hospitalization. The primary outcome measure was medication discrepancies, with the PAC discharge list serving as reference for comparison to the participant's self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies and were organized by common medication classes and risk of harm (eg, 2015 Beers Criteria). Ordinal logistic regression assessed for patient risk factors for PAC discharge discrepancy count. RESULTS A total of 184 participants had 7-day PAC discharge medication data. Participants were predominately female (67%) and Caucasian (83%) with a median of 16 prehospital medications [interquartile range (IQR) 11, 20]. At the 7-day follow-up, 98% of participants had at least 1 medication discrepancy, with a median number of 7 medication discrepancies (IQR 4, 10) per person, 4 (IQR 2, 6) of which were potentially inappropriate medications as defined by the Beers Criteria. Higher medication discrepancies at index hospital admission and receipt of caregiver assistance with medications were 2 key predictors of medication discrepancies in the week after PAC discharge to home. CONCLUSIONS AND IMPLICATIONS Older patients transitioning home from a PAC facility are at high risk for medication discrepancies. This study underscores the need for interventions targeted at this overlooked transition period, especially as patients resume responsibility for managing their own medications after both a hospital and PAC stay.
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Affiliation(s)
- Eduard Eric Vasilevskis
- Division of Hospital Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA; Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Silas P Trumbo
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emily Kay Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Sandra Faye Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Lee JW, Hollingsworth EK, Shah AS, Szanton SL, Perrin N, Mixon AS, Vasilevskis EE, Boyd CM, Han HR, Green AR, Taylor JL, Simmons SF. Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults. J Am Geriatr Soc 2024. [PMID: 38725307 DOI: 10.1111/jgs.18945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 04/01/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. METHODS A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. RESULTS The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. CONCLUSIONS The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.
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Affiliation(s)
- Ji Won Lee
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Columbia University School of Nursing, New York, USA
| | - Emily Kay Hollingsworth
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avantika Saraf Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Nancy Perrin
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Amanda S Mixon
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
| | - Eduard Eric Vasilevskis
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
- Division of Hospital Medicine, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Cynthia M Boyd
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, Baltimore, Maryland, USA
| | - Hae-Ra Han
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Ariel R Green
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, Baltimore, Maryland, USA
| | | | - Sandra Faye Simmons
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Liang MY, Feng L, Zhu W, Yang QQ. Effect of frailty on medication deviation during the hospital-family transition period in older patients with cardiovascular disease: An observational study. Medicine (Baltimore) 2024; 103:e36893. [PMID: 38215090 PMCID: PMC10783343 DOI: 10.1097/md.0000000000036893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024] Open
Abstract
Studies have shown that frailty increases cardiovascular disease (CVD) incidence in older patients and is associated with poor patient prognosis. However, the relationship between medication deviation (MD) and frailty remains unclear. This study aimed to explore the influence of frailty on MD during the hospital-family transition period among older patients with CVD. Between February 2022 and February 2023, 231 older people CVD patients were selected from a class III hospital in Nantong City using a multi-stage sampling method. A general information questionnaire was used to collect the socio-demographic characteristics of the participants prior to discharge, the frailty assessment scale was used to assess the participants frailty, and a medication deviation instrument was used to assess the participants MD on the 10th day after discharge. Propensity score matching was used to examine the effect of frailty on MD in older patients with CVD during the hospital-family transition period. The incidences of frailty and MD were 32.9% (76/231) and 75.8% (175/231), respectively. After propensity score matching, the risk of MD in frail patients with CVD was 4.978 times higher than that in non-frail patients with CVD (95% CI: [1.616, 15.340]; P = .005). Incidences of frailty and MD during the hospital-family transition period are high in older patients with CVD, and frailty has an impact on MD. Medical staff in the ward should comprehensively examine older patients with CVD for frailty and actively promote quality medication management during the hospital-family transition period to reduce MD occurrence and delay disease progression.
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Affiliation(s)
- Meng-Yao Liang
- Department of Nursing, The Sixth People’s Hospital of Nantong, Jiangsu, China
| | - Li Feng
- Department of Nursing, The Sixth People’s Hospital of Nantong, Jiangsu, China
| | - Wuyang Zhu
- Department of Rehabilitation, Yi Jiangmen Community Health Service Center, Gulou District, Nanjing, China
| | - Qing-Qing Yang
- Department of Cardiology, The Sixth People’s Hospital of Nantong, Jiangsu, China
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Pitman SK, Clouse A, Hiner M, So J. Admission medication history quality: Considering nonprescription medications, limited English proficiency, and medication history sources. Am J Health Syst Pharm 2024; 81:e45-e48. [PMID: 37788586 DOI: 10.1093/ajhp/zxad249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Indexed: 10/05/2023] Open
Affiliation(s)
- Stuart K Pitman
- University of Iowa Hospitals and Clinics, Iowa City, IA, and University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Alexis Clouse
- UnityPoint Health-Iowa Methodist Medical Center, Des Moines, IA, USA
| | - Micah Hiner
- M Health Fairview St. John's Hospital, Maplewood, MN, USA
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Coe AB, Rowell BE, Whittaker PA, Ross AT, Nguyen KTL, Bergman N, Farris KB. Impact of an Area Agency on Aging pharmacist-led Community Care Transition Initiative. J Am Pharm Assoc (2003) 2023; 63:1230-1236.e1. [PMID: 37075901 PMCID: PMC10896171 DOI: 10.1016/j.japh.2023.04.008] [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] [Received: 12/13/2022] [Revised: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Rural older adults are at risk of readmissions and medication-related problems after hospital discharge. OBJECTIVES This study aimed to compare 30-day hospital readmissions between participants and nonparticipants and describe medication therapy problems (MTPs) and barriers to care, self-management, and social needs among participants. PRACTICE DESCRIPTION The Michigan Region VII Area Agency on Aging (AAA) Community Care Transition Initiative (CCTI) for rural older adults after hospitalization. PRACTICE INNOVATION Eligible AAA CCTI participants were identified by an AAA community health worker (CHW) trained as a pharmacy technician. Eligibility criteria were Medicare insurance; diagnoses at risk of readmission; length of stay, acuity of admission, comorbidities, and emergency department visits score more than 4; and discharge to home from January 2018 to December 2019. The AAA CCTI included a CHW home visit, telehealth pharmacist comprehensive medication review (CMR), and follow-up for up to 1 year. EVALUATION METHODS A retrospective cohort study examined the primary outcomes of 30-day hospital readmissions and MTPs, categorized by the Pharmacy Quality Alliance MTP Framework. Primary care provider (PCP) visit completion, barriers to self-management, health, and social needs were collected. Descriptive statistics, Mann-Whitney U, and chi-square analyses were used. RESULTS Of 825 eligible discharges, 477 (57.8%) enrolled in the AAA CCTI; differences in 30-day readmissions between participants and nonparticipants were not statistically significant (11.5% vs. 16.1%, P = 0.07). More than one-third of participants (34.6%) completed their PCP visit within 7 days. MTPs were identified in 76.1% of the pharmacist visits (mean MTP 2.1 [SD 1.4]). Adherence (38.2%) and safety-related (32.0%) MTPs were common. Physical health and financial issues were barriers to self-management. CONCLUSION AAA CCTI participants did not have lower hospital readmission rates. The AAA CCTI identified and addressed barriers to self-management and MTPs in participants after the care transition home. Community-based, patient-centered strategies to improve medication use and meet rural adults' health and social needs after care transitions are warranted.
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Kim JL, Lewallen KM, Hollingsworth EK, Shah AS, Simmons SF, Vasilevskis EE. Patient-Reported Barriers and Enablers to Deprescribing Recommendations During a Clinical Trial (Shed-MEDS). THE GERONTOLOGIST 2023; 63:523-533. [PMID: 35881109 PMCID: PMC10028229 DOI: 10.1093/geront/gnac100] [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: 02/28/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Effective deprescribing requires shared decision making between a patient and their clinician, and should be used when implementing evidence-based deprescribing conversations. As part of the Shed-MEDS clinical trial, this study assessed barriers and enablers that influence patient decision making in deprescribing to inform future implementation efforts and adaptations. RESEARCH DESIGN AND METHODS Shed-MEDS, a randomized controlled deprescribing trial, included hospitalized older adults discharging to post-acute care facilities. A trained clinician reviewed each participant's medical history and medication list to identify medications with potential for deprescribing. The study clinician then conducted a semistructured patient-centered deprescribing interview to determine patient (or surrogate) concerns about medications and willingness to deprescribe. Reeve et al.'s (2013) framework was used to categorize barriers and enablers to deprescribing from the patient's perspective, including "appropriateness of cessation," "fear," "dislike of a medication," "influences," and "process of cessation." RESULTS Overall, participants/surrogates (N = 177) agreed with 63% (883 total medications) of the study clinician's deprescribing recommendations. Thematic analysis revealed that "appropriateness" of a medication was the most common barrier (88.2%) and enabler (67.3%) to deprescribing. Other deprescribing enablers were in the following domains: "influences" (22.7%), "process" (22.5%), "pragmatic" (19.4%), and "dislike" (5.3%). DISCUSSION AND IMPLICATIONS Use of a semistructured deprescribing interview conversation tool allowed study clinicians to elicit individual barriers and enablers to deprescribing from the patient's perspective. Participants in this study expressed more agreement than disagreement with study clinicians' deprescribing recommendations. These results should inform future implementation efforts that incorporate a patient-centered framework during deprescribing conversations. CLINICAL TRIALS REGISTRATION NUMBER NCT02979353.
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Affiliation(s)
- Jennifer L Kim
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Kanah M Lewallen
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Emily K Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avantika S Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, & Clinical Center (GRECC), VA Tennessee Healthcare System, Nashville, Tennessee, USA
| | - Eduard E Vasilevskis
- Geriatric Research, Education, & Clinical Center (GRECC), VA Tennessee Healthcare System, Nashville, Tennessee, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ho JMW, Rofaiel R, Wang K, To E, Liu B, Antoniou T, Benjamin S, Bodkin RJ. Medication discrepancies in older adults receiving asynchronous virtual care. J Am Geriatr Soc 2022; 70:3633-3636. [PMID: 36089761 DOI: 10.1111/jgs.17971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Joanne Man-Wai Ho
- Department of Medicine, McMaster University, Kitchener, Ontario, Canada.,Schlegel Research Institute for Aging, Waterloo, Ontario, Canada.,GeriMedRisk, Waterloo, Ontario, Canada
| | - Rymon Rofaiel
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada.,Division of General Internal Medicine & Geriatrics, Halton Healthcare, Oakville, Ontario, Canada
| | | | - Eric To
- Department of Medicine, McMaster University, Kitchener, Ontario, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tony Antoniou
- GeriMedRisk, Waterloo, Ontario, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sophiya Benjamin
- GeriMedRisk, Waterloo, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Kitchener, Ontario, Canada.,Grand River Hospital, Kitchener, Ontario, Canada
| | - Robert Jack Bodkin
- GeriMedRisk, Waterloo, Ontario, Canada.,Grand River Hospital, Kitchener, Ontario, Canada
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