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Ndai AM, Morris EJ, Winterstein AG, Vouri SM. Evaluating Provider and Pharmacy Discordance in Potential Calcium Channel Blocker-Loop Diuretic Prescribing Cascade. Drugs Aging 2024; 41:177-186. [PMID: 38252391 DOI: 10.1007/s40266-023-01091-9] [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: 12/17/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prescribing cascades occur when a drug-induced adverse event is treated with a new medication. Identifying clinical scenarios in which prescribing cascades are more likely to occur may help determine ways to prevent prescribing cascades. OBJECTIVE To understand the extent to which discordant providers and discordant pharmacies contribute to the dihydropyridine calcium channel blocker (DH CCB)-loop diuretic prescribing cascade. STUDY POPULATION AND DESIGN A retrospective cohort study using Medicare Fee-For-Service data (2011-2018) of adults aged ≥ 66 years. EXPOSURES Patients who initiated DH CCB with subsequent initiation of loop diuretic (DH CCB-loop diuretic dyad) within 90 days or patients who initiated angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) with subsequent initiation of a loop diuretic (ACEI/ARB-loop diuretic dyad; control). MAIN OUTCOMES The primary outcomes were provider and pharmacy discordance for prescribing cascades and control drug pairs. Baseline clinical and socio-demographic characteristics were balanced using inverse probability of treatment weighting with propensity scores. RESULTS Overall, we identified 1987 DH CCB-loop diuretic dyads and 3148 ACEI/ARB-loop diuretic dyads. Discordant providers occurred in 64% of DH CCB-loop diuretic dyads and 55% of ACEI/ARB-loop diuretic dyads, while discordant pharmacies occurred in 19% of DH CCB-loop diuretic dyads and 16% of ACEI/ARB-loop diuretic dyads. After adjustment, the risk of having discordant providers was 20% {Relative Risk (RR) 1.20 [95% confidence interval (CI), 1.14-1.26]} higher in the DH CCB-loop diuretic dyad compared with the ACEI/ARB-loop diuretic dyad. Moreover, pharmacy discordance was 17% (RR 1.17 [95% CI 1.02-1.33]) higher. CONCLUSION Our findings suggest that discordant providers and discordant pharmacies were more commonly involved in the potential prescribing cascade when compared with a similar control dyad of medications. Opportunities for enhanced care coordination and medication reconciliation should be explored to prevent unnecessary polypharmacy.
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Affiliation(s)
- Asinamai M Ndai
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
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Gendre P, Mayol S, Mocquard J, Huon JF. Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors. Basic Clin Pharmacol Toxicol 2023; 133:718-728. [PMID: 37081726 DOI: 10.1111/bcpt.13878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Clinical pharmacists have a pivotal role in the management of the patient's medication. However, it is necessary to know how pharmacist-mediated deprescribing could be implemented in a hospital setting according to hospital physicians. OBJECTIVE To explore physicians' views on the involvement of hospital pharmacists in the deprescribing process using the example of PPIs. METHODS A qualitative study using two focus groups with hospital physicians was conducted to determine their attitudes regarding deprescribing initiated by the hospital pharmacist. The interviews were recorded and transcribed using the NVivo analysis software. A thematic analysis led to a categorization of all the verbatims. RESULTS Hospital doctors are reluctant to deprescribe drugs initiated by a colleague and feel that it is the responsibility of the general practitioner (GP), who fails to do so due to lack of time. In this situation, the hospital pharmacist is in the best position to deprescribe because of his/her expertise in drug therapy. This should be a discussion between the hospital pharmacist, the hospital doctor, the GP and the patient. Deprescribing should always be adapted to the patient's context. CONCLUSION Hospital physicians are open to a pharmacist-mediated, patient-centred approach to deprescribing as long as the GP is involved.
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Affiliation(s)
- Pauline Gendre
- CHU Nantes, Pharmacy Department, Nantes University, Nantes, France
| | | | - Julie Mocquard
- CHU Nantes, Pharmacy Department, Nantes University, Nantes, France
| | - Jean-François Huon
- CHU Nantes, Pharmacy Department, Nantes University, Nantes, France
- INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, Nantes, France
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Cheng C, Yu H, Wang Q. Nurses' Experiences Concerning Older Adults with Polypharmacy: A Meta-Synthesis of Qualitative Findings. Healthcare (Basel) 2023; 11:healthcare11030334. [PMID: 36766909 PMCID: PMC9914425 DOI: 10.3390/healthcare11030334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Polypharmacy is an increasing health concern among older adults and results in many health risks. Nurses have an important role to play in supporting medication management and promoting medication safety across different settings. This study aims to provide a meta-synthesis of qualitative studies investigating the perceptions and experiences of nurses in caring for older adults with polypharmacy. Electronic databases including PsycArticles, CINAHL Complete, MEDLINE, and ERIC were searched between September 2001 and July 2022. Potential studies were checked against inclusion and exclusion criteria. We included peer-reviewed studies reporting data on the experiences of nursing staff across different settings. Studies unitizing any qualitative approach were included, and the included studies were reviewed and analyzed using a thematic synthesis approach. Study quality was examined using the Critical Appraisal Skills Programme checklist for qualitative research. A total of nine studies with 91 nurses were included. Four major themes emerged: older adults suffering from polypharmacy, the importance of multidisciplinary teams, nursing roles in caring for older adults, and the complexity and barriers of implementing polypharmacy management. Healthcare professionals should pay attention to the impacts of polypharmacy in older adults' lives and should acknowledge the importance of team-based polypharmacy care in supporting older adults. Nurses play a key role in caring for older adults with polypharmacy, therefore, they should be empowered and be involved in medication management.
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Affiliation(s)
- Cheng Cheng
- School of Nursing, Fudan University, Shanghai 200032, China
- Correspondence: ; Tel.: +86-21-64431003
| | - Huan Yu
- School of Nursing, Anhui Medical University, Hefei 230032, China
| | - Qingling Wang
- School of Nursing and Health Management, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China
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4
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Ozavci G, Bucknall T, Woodward-Kron R, Hughes C, Jorm C, Joseph K, Manias E. Knowledge and Power Relations in Older Patients' Communication About Medications Across Transitions of Care. QUALITATIVE HEALTH RESEARCH 2021; 31:2678-2691. [PMID: 34657517 DOI: 10.1177/10497323211043494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients' experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough's Critical Discourse Analysis and Medication Communication Model. Older patients' medication knowledge and family members' advocacy challenged unequal power relations between clinicians and patients and families. Doctors' use of authoritative discourse impeded older patients' participation in the medication communication. Older patients perceived that nurses' involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.
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Affiliation(s)
- Guncag Ozavci
- Deakin University, Burwood, Victoria, Australia
- Alfred Health, Melbourne, Australia
| | - Tracey Bucknall
- Deakin University, Burwood, Victoria, Australia
- Alfred Health, Melbourne, Australia
| | | | - Carmel Hughes
- Queen's University Belfast, Belfast, Northern Ireland
| | - Christine Jorm
- NSW Regional Health Partners, Newcastle, New South Wales, Australia
| | - Kathryn Joseph
- Deakin University, Burwood, Victoria, Australia
- Alfred Health, Melbourne, Australia
| | - Elizabeth Manias
- Deakin University, Burwood, Victoria, Australia
- Alfred Health, Melbourne, Australia
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Alshammari H, Al-Saeed E, Ahmed Z, Aslanpour Z. Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review. Drug Healthc Patient Saf 2021; 13:183-210. [PMID: 34764701 PMCID: PMC8572741 DOI: 10.2147/dhps.s303101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 07/16/2021] [Indexed: 12/29/2022] Open
Abstract
Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.
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Affiliation(s)
- Hesah Alshammari
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Correspondence: Hesah Alshammari Email
| | - Eman Al-Saeed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zamzam Ahmed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Aguilera C, Agustí A, Pérez E, Gracia RM, Diogène E, Danés I. Spontaneously Reported Adverse Drug Reactions and Their Description in Hospital Discharge Reports: A Retrospective Study. J Clin Med 2021; 10:jcm10153293. [PMID: 34362076 PMCID: PMC8348023 DOI: 10.3390/jcm10153293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
The inclusion of spontaneously reported adverse drug reactions (ADRs) in hospital discharge reports was examined, in addition to the factors associated with their inclusion, the resulting therapeutic decisions, and any recommendations made upon patient discharge regarding the suspected offending drugs. ADRs that were spontaneously reported during 2017 and 2018 to the pharmacovigilance program were retrospectively analyzed. Information regarding patient characteristics, drug treatments, and ADRs was collected from the ADR notifications and from patient electronic medical records. The dependent variable was the mentioning of ADRs in the discharge reports, while characteristics of the ADRs, pharmacovigilance causality algorithms, and some of the suspected drugs themselves were the independent variables during bivariant analysis. A total of 286 reports of suspected ADRs from 271 patients (50.2% female; 77% adults) were included. Information regarding the ADRs was present in the discharge reports for 238 reports (83.2%); the ADR seriousness and the lack of potential alternative causes were the only associated factors. Withdrawal or withdrawal and substitution by an alternative drug were the most common therapeutic decisions, although often no recommendation was made. Overall, there is still room for improvement in terms of including information related to ADRs in hospital discharge reports.
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Affiliation(s)
- Cristina Aguilera
- Clinical Pharmacology Service, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08001 Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, 08001 Barcelona, Spain
- Immunomediated Diseases and Innovative Therapies Group, Vall d'Hebron Research Institute, 08001 Barcelona, Spain
| | - Antònia Agustí
- Clinical Pharmacology Service, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08001 Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, 08001 Barcelona, Spain
- Immunomediated Diseases and Innovative Therapies Group, Vall d'Hebron Research Institute, 08001 Barcelona, Spain
| | - Eulàlia Pérez
- Clinical Pharmacology Service, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08001 Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, 08001 Barcelona, Spain
| | - Rosa M Gracia
- Intensive Care Unit Service, Vall d'Hebron University Hospital, 08001 Barcelona, Spain
| | - Eduard Diogène
- Clinical Pharmacology Service, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08001 Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, 08001 Barcelona, Spain
- Immunomediated Diseases and Innovative Therapies Group, Vall d'Hebron Research Institute, 08001 Barcelona, Spain
| | - Immaculada Danés
- Clinical Pharmacology Service, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08001 Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, 08001 Barcelona, Spain
- Immunomediated Diseases and Innovative Therapies Group, Vall d'Hebron Research Institute, 08001 Barcelona, Spain
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7
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Gerlach N, Michiels-Corsten M, Viniol A, Schleef T, Junius-Walker U, Krause O, Donner-Banzhoff N. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study. BMC FAMILY PRACTICE 2020; 21:183. [PMID: 32887551 PMCID: PMC7487755 DOI: 10.1186/s12875-020-01255-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022]
Abstract
Background Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs’, community pharmacists’ and specialist providers’ role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches. Method Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework. Results Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains ‘Social/professional role and identity’ (1), ‘Social influences’ (2), ‘Reinforcement’ (3) and ´Environmental context and resources’ (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients’ trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs’ role and deprescribing attempts. Reinforcements (3) negatively affected GPs’ and pharmacists’ effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized. Conclusion Understanding stakeholders’ role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.
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Affiliation(s)
- Navina Gerlach
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany.
| | - Matthias Michiels-Corsten
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
| | - Annika Viniol
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
| | - Tanja Schleef
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Ulrike Junius-Walker
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Olaf Krause
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
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Bilek AJ, Levy Y, Kab H, Andreev P, Garfinkel D. Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings. Ther Adv Drug Saf 2019; 10:2042098619895914. [PMID: 31908757 PMCID: PMC6935879 DOI: 10.1177/2042098619895914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/27/2019] [Indexed: 01/22/2023] Open
Abstract
Background In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing. Methods This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill. Results In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives. Conclusions A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.
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Affiliation(s)
- Aaron Jason Bilek
- Geriatrics Department, Tel Aviv Sourasky Medical Center, Weizmann Street 6, Tel Aviv 64239, Israel
| | - Yuval Levy
- Deputy Director General Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Haneen Kab
- Pharmacy Department at Hebrew University, Jerusalem, Israel
| | - Pavel Andreev
- Department of Medicine C, Wolfson Medical Center, Holon, Israel
| | - Doron Garfinkel
- Medical Center, Ramat Gan, Israel Homecare Hospice, Israel Cancer Association, Givatayim, Israel IGRIMUP (International Group for Reducing Inappropriate Medication Use and Polypharmacy), Bat Yam, Israel
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Wouters H, Foster JM, Ensink A, O'Donnell LK, Zuidema SU, Boersma F, Taxis K. Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study. Front Pharmacol 2019; 10:1026. [PMID: 31619991 PMCID: PMC6759938 DOI: 10.3389/fphar.2019.01026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/12/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Juliet M Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Anne Ensink
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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10
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Wouters H, Foster JM, Ensink A, O'Donnell LK, Zuidema SU, Boersma F, Taxis K. Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study. Front Pharmacol 2019. [PMID: 31619991 DOI: 10.3389/fphar.2019.01026/full] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Juliet M Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Anne Ensink
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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Anrys PM, Strauven GC, Foulon V, Degryse JM, Henrard S, Spinewine A. Potentially Inappropriate Prescribing in Belgian Nursing Homes: Prevalence and Associated Factors. J Am Med Dir Assoc 2018; 19:884-890. [DOI: 10.1016/j.jamda.2018.06.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/07/2018] [Accepted: 06/11/2018] [Indexed: 01/07/2023]
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13
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Heser K, Pohontsch NJ, Scherer M, Löffler A, Luck T, Riedel-Heller SG, Maier W, Parker D, Haenisch B, Jessen F. Perspective of elderly patients on chronic use of potentially inappropriate medication - Results of the qualitative CIM-TRIAD study. PLoS One 2018; 13:e0202068. [PMID: 30231027 PMCID: PMC6145513 DOI: 10.1371/journal.pone.0202068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 07/28/2018] [Indexed: 11/18/2022] Open
Abstract
Although potentially inappropriate medication (PIM) is associated with risk of harm due to adverse effects, it is frequently prescribed for elderly patients. The aim of this qualitative multi-center study was to gain insight into contextual factors that might lead to chronic PIM use. We conducted semi-structured interviews with elderly patients with or without chronic PIM use (patient interviews: n = 52). Patients were between 86 and 96 years old. The participants were recruited from the AgeCoDe study. Interviews were audiotaped and transcribed verbatim. The transcripts of the interviews were analysed using qualitative content analysis. Deductive and inductive categories were determined. We found contextual factors related to the patient and related to patient-general practitioner (GP) communication that might lead to chronic PIM use (i.e., positive features of PIM, maintaining characteristics of medication intake, barriers to deprescribe PIM, external actors supporting PIM intake, system-related factors). Besides certain health-related behaviours (e.g., own obligation to report to GP) and medication-related attitudes and knowledge (e.g., awareness of side effects and interaction of medicines), patient-GP-interactions that were characterised by mutual agreements on drugs (e.g., concerning dosage or discontinuation of a drug) might be advantageous to reduce the probability of chronic PIM use. The results might assist in the development of guidelines and educational programs aiming to reduce PIM use in the elderly.
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Affiliation(s)
- Kathrin Heser
- Department for Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
- * E-mail:
| | - Nadine Janis Pohontsch
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antje Löffler
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Leipzig, Germany
- Institute of Health Science, Brandenburg University of Technology (BTU) Cottbus-Senftenberg, Senftenberg, Germany
| | - Tobias Luck
- Department of Economic and Social Sciences & Institute of Social Medicine, Rehabilitation Sciences and Healthcare Research (ISRV), University of Applied Sciences Nordhausen, Nordhausen, Germany
| | - Steffi G. Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Leipzig, Germany
| | - Wolfgang Maier
- Department for Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Debora Parker
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
- Center for Translational Medicine, University of Bonn, Bonn, Germany
| | - Frank Jessen
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
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14
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Pohontsch NJ, Löffler A, Luck T, Heser K, Parker D, Haenisch B, Riedel-Heller SG, Jessen F, Scherer M. Informal caregivers' perspectives on health of and (potentially inappropriate) medication for (relatively) independent oldest-old people - a qualitative interview study. BMC Geriatr 2018; 18:169. [PMID: 30045689 PMCID: PMC6060533 DOI: 10.1186/s12877-018-0849-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Oldest-old persons frequently receive potentially inappropriate medication. Medication use takes place under the patients' informal caregivers' influence. We explored informal caregivers' perspectives on medication of (relatively) independent oldest-old persons to identify starting points for safer medication prescription/handling. METHODS In this exploratory qualitative interview study we interviewed 45 informal caregivers of 45 oldest-old persons (23 with potentially inappropriate medication/22 without potentially inappropriate medication). Interviews were recorded, transcribed and content analyzed (deductive/inductive coding). RESULTS Interviewees had little knowledge about/influence on oldest-old persons' medication, but declared to monitor oldest-old persons' needs for assistance. They were unaware of the concept of potentially inappropriate medication but sometimes sensitive to substance dependency. Most informal caregivers were satisfied with the oldest-old persons' medication and viewed medication as increasing the patients' quality of life. Inadequate communication was found between informal caregivers and general practitioners. CONCLUSIONS Influence of informal caregivers on (relatively) independent oldest-old persons' medication seems low. Stakeholders need to be aware that there is a transitional period where independency of oldest-old persons decreases and support needs increase which may be missed by (in-)formal caregivers or concealed by oldest-old persons. Monitoring patients' medication competencies; measures supporting communication between informal caregivers and health care professionals; provision of educational and support resources for informal caregivers and the acceptance of oldest-old persons' increasing assistance needs may increase medication safety.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Antje Löffler
- Institute of Health Science, Brandenburg University of Technology (BTU) Cottbus-Senftenberg, Senftenberg, Germany
| | - Tobias Luck
- Department of Economic and Social Sciences & Institute of Social Medicine, Rehabilitation Sciences and Healthcare Research (ISRV), University of Applied Sciences Nordhausen, Nordhausen, Germany
| | - Kathrin Heser
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Debora Parker
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
- Center for Translational Medicine, University of Bonn, Bonn, Germany
- Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Steffi G. Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Leipzig, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Martin Scherer
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Krzyzaniak N, Singh S, Bajorek B. Physicians’ perspectives on defining older adult patients and making appropriate prescribing decisions. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Innovations in Insomnia Management: A Review of Current Approaches and Novel Targets Including Orexin Receptor Antagonists. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Abstract
Current ACGME regulations have limited residents' weekly hours and continuous working hours, a marked change, despite its uncertain effects on physician well-being and quality of care. Although residency programs in internal medicine and family medicine have adapted schedules to conform to these regulations, increasing evidence is accumulating to suggest that these training experiences are not adequately preparing the next generation of practicing primary care and hospital-based physicians. Data from an array of sources continue to demonstrate significant deficiencies in six areas of residents' responsibilities towards their patients: diminished patient "face time" and direct patient care; focus on patients' "reason for hospitalization" or "reason for visit" at the expense of possible neglect of patients' "secondary" medical problems; limited attention to patients' emotional or contextual problems and limited empathy; deficient implementation of the essential constituents of patient-centered care; neglect of habitual "reflective practice"; and excessive distinction between inpatient and outpatient responsibilities, leading to missed opportunities for inpatient residents to be aware of and attend to patients' post-discharge course although new information and readmissions related to the index hospitalization are prevalent. Thus, redesigning residency programs to widen residents' outlook and cover these inseparable components of high-quality care, may infuse the often fatigued and burnt-out residents with purpose and fulfillment, finally incorporating the missing elements of patient-centered care as integral parts of patients' admissions and therefore, of physicians' future careers.
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Affiliation(s)
- Ami Schattner
- a The Faculty of Medicine , Hadassah Medical School, Hebrew University , Jerusalem , Israel
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18
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Schmiemann G, Dehlfing A, Pulst A, Hoffmann F. [Medication safety in nursing home residents with renal insufficiency - Results of a qualitative study]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2017; 121:14-20. [PMID: 28347697 DOI: 10.1016/j.zefq.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/08/2017] [Accepted: 02/26/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Nursing home residents often suffer from multimorbidity and polypharmacy. Impaired renal function and the lack of dose adjustments further increase the risk of adverse drug reactions (ADR). The aims of this qualitative study were to analyze the reasons for inadequate drug treatment and to identify possible intervention options to improve safety of drug treatment in nursing home residents with renal insufficiency. METHODS Using a mixed-method approach a cross-sectional study and focus group discussions were performed in the project. Focus groups with general practitioners, nursing staff, nephrologists and pharmacists were held. Audiotapes were transcribed verbatim, qualitative content analysis of the transcripts according to Mayring was conducted using MAXQDA. RESULTS AND CONCLUSIONS Focus groups discussed different aspects and possible interventions related to inadequate drug treatment in nursing home residents with renal insufficiency. The main topics identified were "health service situation", "reasons for ADR" and "interventions". Regarding the current health service situation "infrastructure", "role of polypharmacy", "assessment of renal function" and the "different role models" were identified as relevant aspects for improving the safety of drug treatment in nursing homes. According to the participants, there is a lack of evidence-based standards regarding laboratory monitoring and estimation of kidney function.
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Affiliation(s)
- Guido Schmiemann
- Abteilung Versorgungsforschung, Institut für Public Health und Pflegeforschung (IPP), Universität Bremen, Bremen, Deutschland; Health Sciences Bremen, Universität Bremen, Deutschland.
| | - Anne Dehlfing
- Abteilung Versorgungsforschung, Institut für Public Health und Pflegeforschung (IPP), Universität Bremen, Bremen, Deutschland; Health Sciences Bremen, Universität Bremen, Deutschland
| | - Alexandra Pulst
- Abteilung Versorgungsforschung, Institut für Public Health und Pflegeforschung (IPP), Universität Bremen, Bremen, Deutschland; Health Sciences Bremen, Universität Bremen, Deutschland
| | - Falk Hoffmann
- Department für Versorgungsforschung, Fakultät für Medizin und Gesundheitswissenschaft, Carl von Ossietzky Universität Oldenburg, Oldenburg, Deutschland
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19
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Pohontsch NJ, Heser K, Löffler A, Haenisch B, Parker D, Luck T, Riedel-Heller SG, Maier W, Jessen F, Scherer M. General practitioners' views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients-A qualitative interview study with GPs (CIM-TRIAD study). BMC FAMILY PRACTICE 2017; 18:22. [PMID: 28212616 PMCID: PMC5395870 DOI: 10.1186/s12875-017-0595-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/26/2017] [Indexed: 12/13/2022]
Abstract
Background Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners’ views on PIM and aspects affecting the (long-term) use of PIM. Methods As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. Results The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners’ point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. “demanding high-user”, positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. Conclusions While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, “positive lists”, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0595-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Kathrin Heser
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Antje Löffler
- Institute of Health, Brandenburg University of Technology, Großenhainer Straße 57, 01968, Senftenberg, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Debora Parker
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Frank Jessen
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany.,Clinic and polyclinic for psychiatry and psychotherapy, University Medical Center Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Martin Scherer
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Cullinan S, Raae Hansen C, Byrne S, O'Mahony D, Kearney P, Sahm L. Challenges of deprescribing in the multimorbid patient. Eur J Hosp Pharm 2016; 24:43-46. [PMID: 31156897 DOI: 10.1136/ejhpharm-2016-000921] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Older patients often have multimorbidity, frequently resulting in polypharmacy. Independently, multimorbidity and polypharmacy are among the biggest risk factors for inappropriate medication, adverse drug reactions, adverse drug events and morbidity, leading to patient harm and hospitalisations. After a medication review, discontinuation of medication or deprescribing is one of the most common recommendations but is likely to be ignored. The deprescribing process includes some or all of the following elements: a review of current medications, identification of medications to be discontinued, a discontinuation regimen, involvement of patients and a review with follow-up. In addition to the complexity presented by prescribing or deprescribing for older multimorbid patients, other factors act as barriers to discontinuation of medications in these patients; these include interprofessional relationships, difficulties with medication reviews, deficiencies in knowledge and evidence and patients' preferences/resistance to change. These challenges are compounded by the need to manage the shared treatment of multiple conditions by several prescribers from different specialties based on disease-specific guidelines without evidence of effects on the older, frailer, multimorbid patients. The interdisciplinary effort in the treatment of such patients needs to improve to ensure that we treat the patient holistically and not just the individual conditions of the multimorbid patient, according to guidelines. We must first, however, equip prescribers to identify instances where deprescribing is appropriate and then make the necessary changes to pharmacotherapy.
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Affiliation(s)
- Shane Cullinan
- School of Pharmacy, University College Cork, Cork, Ireland
| | | | - Stephen Byrne
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Denis O'Mahony
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Patricia Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Laura Sahm
- School of Pharmacy, University College Cork, Cork, Ireland
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Bokhof B, Junius-Walker U. Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies. Drugs Aging 2016; 33:249-66. [PMID: 26915076 DOI: 10.1007/s40266-016-0354-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Polypharmacy, common in elderly multimorbid adults, leads to increased iatrogenic health risks. Yet, no consistent approach to stopping medicines exists in primary healthcare. OBJECTIVES Our objective was to synthesize qualitative studies exploring the perspectives and experiences of general practitioners (GPs) and older patients in reducing polypharmacy and to discover approaches already being practiced. METHODS We conducted a search in the PubMed, Cochrane Library, Web of Science Core Collection, and Scopus databases to identify qualitative studies in the primary care setting addressing multimorbid older patients and polypharmacy reduction. The seven-step model of meta-ethnography allowed for cross-interpretation between studies considering their original context and developing theories. RESULTS A total of 14 studies from the perspectives of patients (n = 6) and providers (n = 8) were included, although discontinuing medicines only occurred as a sub-theme in patient studies. Emerging key concepts for patients were experimenting with medicines, attitudes and experiences towards medicines, necessity of prioritizing treatments, relationship to GP, and system-related contributors. For GPs, they covered assumptions about elderly patients, interface prescribing problems, evidence-based guidelines, failure to meet the challenge of complex decision-making, and solutions. DISCUSSION Complex medication regimens and uncertainties in decision making are challenges for both GPs and patients. For patients, symptom experiences with medicines, relationship with their prescriber, and fragmented care are at the forefront; for GPs, it is the decision-making responsibility in the context of unsuitable guidelines, time constraints, and deficient multidisciplinary co-operation. Heuristics such as prioritizing and individualizing treatments and relaxation of guidelines emerged. These strategies require professional awareness of the problem and establishing a trusting, patient-centered consultation style and supportive work conditions.
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Affiliation(s)
- Beate Bokhof
- Institute of General Practice, Hannover, Lower Saxony, Germany.
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23
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A Short History of the Development of Hospital Pharmacy in Belgium. PHARMACY 2016; 4:pharmacy4030025. [PMID: 28970398 PMCID: PMC5419363 DOI: 10.3390/pharmacy4030025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/22/2016] [Accepted: 08/09/2016] [Indexed: 12/03/2022] Open
Abstract
The Belgian Association of Hospital Pharmacists (BAHP) is a professional and scientific association representing all pharmacists who work in hospital institutions, whether private or public, university, general or psychiatric. This association was created in 1953. The aim of this short paper is to tell the history of its continuous development in a few words. The main development is reviewed from 1950 to now including: regulation, professional association roles, agreement and continuing education, development of clinical pharmacy, and updating of university training program. A new decree for the hospital pharmacist is in the course of being finalized, including new technologies: automated dispensing, automated compounding, centralization of sterile compounding, e-learning, traceability of medical devices and clinical pharmacy.
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Clyne B, Cooper JA, Hughes CM, Fahey T, Smith SM. 'Potentially inappropriate or specifically appropriate?' Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people. BMC FAMILY PRACTICE 2016; 17:109. [PMID: 27515854 PMCID: PMC4982127 DOI: 10.1186/s12875-016-0507-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/03/2016] [Indexed: 11/12/2022]
Abstract
Background Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Method Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Results Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Conclusions Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.
| | - Janine A Cooper
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.,School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
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Kouladjian L, Gnjidic D, Reeve E, Chen TF, Hilmer SN. Health Care Practitioners’ Perspectives on Deprescribing Anticholinergic and Sedative Medications in Older Adults. Ann Pharmacother 2016; 50:625-36. [DOI: 10.1177/1060028016652997] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Anticholinergic and sedative (ACh-Sed) medications are commonly prescribed for older adults and are associated with adverse events. Objectives: (1) To investigate perspectives of health care practitioners (HCPs) surrounding deprescribing (withdrawal) of ACh-Sed medications in older adults; (2) to assess HCPs’ perspectives on the design and implementation of a report on a patient’s exposure to ACh-Sed medications using the Drug Burden Index (DBI) pharmacological tool. Methods: This was a qualitative study using focus groups with purposive samples of accredited pharmacists (APs), general practitioners (GPs), and specialist physicians (SPs). Participants were also asked to comment on a sample DBI report of a hypothetical patient and its potential role in practice. The discussions were audiorecorded, transcribed verbatim, and thematically analyzed to derive conceptual domains. QSR NVivo Version 10 was used for data management. Results: Several barriers and enablers to deprescribing ACh-Sed medications in older adults were identified. The most noteworthy barrier to deprescribing related to devolving responsibility. Predominantly, APs expressed frustration surrounding disregard by GPs of their recommendations to deprescribe medications. GPs expressed that deprescribing should be conducted by SPs and vice versa. The DBI report supported and addressed some of the identified barriers to deprescribing ACh-Sed medications in older adults. The HCPs also identified several opportunities and considerations for implementing the DBI report in practice, mainly highlighting that ACh-Sed medications are not the only high-risk medications for older people. Conclusions: Although HCPs recognize the harms associated with ACh-Sed medication use, they devolve prescribing and management responsibility to other groups of HCPs.
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Affiliation(s)
- Lisa Kouladjian
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Danijela Gnjidic
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Emily Reeve
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Dalhousie University, Nova Scotia, Canada
| | - Timothy F. Chen
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
| | - Sarah N. Hilmer
- Kolling Institute of Medical Research, St Leonards, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Palagyi A, Keay L, Harper J, Potter J, Lindley RI. Barricades and brickwalls--a qualitative study exploring perceptions of medication use and deprescribing in long-term care. BMC Geriatr 2016; 16:15. [PMID: 26767619 PMCID: PMC4714480 DOI: 10.1186/s12877-016-0181-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background The co-administration of multiple drugs (polypharmacy) is the single most common cause of adverse drug events in the older population, and residents of long-term care facilities (LTCFs) are at particularly high risk of medication harm. ‘Deprescribing’ – the withdrawal of an inappropriate medication with goal of managing polypharmacy and improving outcomes – may improve the quality of life of LTCF residents. The RELEASE study sought to explore perceptions of medication use and the concept of deprescribing in LTCFs. Methods Focus groups and interviews were conducted with General Practitioners (GPs), pharmacists, nursing staff, residents and their relatives within three LTCFs in the Illawarra-Shoalhaven region of NSW, Australia. Audiotapes were transcribed verbatim and, using the Integrative Model of Behaviour Prediction as a framework, thematic analysis of transcripts was conducted using QSR NVivo 10. Results Participants acknowledged the burden of too many medications (time to administer, physical discomfort, cost), yet displayed passivity towards medication reduction. Residents and relatives lacked understanding of medicine indications or potential harms. Willingness to initiate and accept medication change was dependent on the GP, who emerged as a central trusted figure. GPs preferred ‘the path of least resistance’, signalling systems barriers (poor uniformity of LTCF medical records, limited trained LTCF personnel); time constraints (resident consultations, follow-up with specialists and family); and the organisation of care (collaborating with LTCF staff, pharmacists and prescribing specialists) as obstacles to deprescribing. Conclusions Targeted engagement is required to raise awareness of the risks of polypharmacy in LTCFs and encourage acceptance of deprescribing amongst residents and their relatives. GPs are integral to the success of deprescribing initiatives within this sector. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0181-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Palagyi
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Lisa Keay
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Jessica Harper
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Jan Potter
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia. .,Illawarra-Shoalhaven Local Health District, Wollongong, NSW, Australia.
| | - Richard I Lindley
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Andrade LF, Sermet C, Pichetti S. Entry time effects and follow-on drug competition. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:45-60. [PMID: 25501258 DOI: 10.1007/s10198-014-0654-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 11/04/2014] [Indexed: 05/08/2023]
Abstract
Pharmaceutical firms have been criticized for concentrating efforts of R&D on the so-called me-too or follow-on drugs. There have been many comments for and against the dissemination of these incremental innovations but few papers have broached the subject from an econometric point of view, possibly because identification of me-too or follow-on drugs is not so obvious. This paper focuses on the impact of entry order on follow-on drug competition in the French market between the years 2001 and 2007. More precisely, this study examines the effects on market share of first entrants in the follow-on drug market and how this possible competitive advantage changes over time. First results are coherent with theoretical microeconomic issues concerning the importance of being first. We find evidence that first movers in the follow-on drug market have the ability to capture and maintain greater market share for a long period of time. The hierarchical market position of follow-on drugs does not seem to be affected by generic drug emergence. From a dynamic perspective, our analysis shows that market share is positively correlated with the ability of follow-on drugs to set prices higher than the average follow-on drug prices in a specific therapeutic class, which means that market power remains considerably important for first movers. Moreover, we found that the optimum level of innovation to maximize market share is the highest one.
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Kydd A, Fleming A. Ageism and age discrimination in health care: Fact or fiction? A narrative review of the literature. Maturitas 2015; 81:432-8. [DOI: 10.1016/j.maturitas.2015.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/11/2015] [Indexed: 10/23/2022]
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Abstract
BACKGROUND Many studies analyse the diagnostic process, diagnostic errors and diagnostic excellence but few provide a broad, yet practical view of this complex and highly context-dependent challenge. METHODS A personal, experience- and research-based selection of the principles of data collection, processing and clinical reasoning found to be most useful in achieving an efficient, timely and patient-centered diagnosis. RESULTS Twenty-four principles were identified and each one is presented followed by a brief commentary. CONCLUSIONS No single strategy can provide a solution for all diagnostic problems. However, the 24 principles have proven validity and can be applied for solving diagnostic problems in varied settings and as a scaffold in teaching diagnosis at all levels of medical education.
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Affiliation(s)
- A Schattner
- From the Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK and Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel From the Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK and Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Cullinan S, Fleming A, O'Mahony D, Ryan C, O'Sullivan D, Gallagher P, Byrne S. Doctors' perspectives on the barriers to appropriate prescribing in older hospitalized patients: a qualitative study. Br J Clin Pharmacol 2015; 79:860-9. [PMID: 25403269 PMCID: PMC4415722 DOI: 10.1111/bcp.12555] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/12/2014] [Indexed: 12/01/2022] Open
Abstract
AIMS Older patients commonly suffer from multimorbidites and take multiple medications. As a result, these patients are more vulnerable to potentially inappropriate prescribing (PIP). PIP in older patients may result in adverse drug events (ADEs) and hospitalizations. However, little has been done to identify why PIP occurs. The objectives of this study were (i) to identify hospital doctors' perceptions as to why PIP occurs, (ii) to identify the barriers to addressing the issues identified and (iii) to determine which intervention types would be best suited to improving prescribing. METHODS Semi-structured interviews based on the Theoretical Domains Framework (TDF), a tool used to apply behaviour change theories, were conducted with 22 hospital doctors. Content analysis was conducted to identify domains of the TDF that could be targeted to improve prescribing for older people. These domains were then mapped to the behaviour change wheel to identify possible intervention types. RESULTS Content analysis identified five of the 12 domains in the TDF as relevant: (i) environmental context and resources, (ii) knowledge, (iii) skills, (iv) social influences and (v) memory/attention and decision processes. Using the behaviour change wheel, the types of interventions deemed suitable were those based on training and environmental restructuring. CONCLUSION This study shows that doctors feel there is insufficient emphasis on geriatric pharmacotherapy in their undergraduate/postgraduate training. An intervention providing supplementary training, with particular emphasis on decision processes and dealing with social influences would be justified. This study has, however, uncovered many areas for potential intervention in the future.
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Affiliation(s)
- Shane Cullinan
- Pharmaceutical Care Research Group, School of Pharmacy, University College CorkCork, Ireland
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College CorkCork, Ireland
| | - Denis O'Mahony
- Department of Geriatric Medicine, Cork University Hospital and School of Medicine, University College CorkCork, Ireland
| | - Cristin Ryan
- School of Pharmacy, Queen's University BelfastBelfast, UK
| | - David O'Sullivan
- Pharmaceutical Care Research Group, School of Pharmacy, University College CorkCork, Ireland
| | - Paul Gallagher
- School of Pharmacy, Queen's University BelfastBelfast, UK
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College CorkCork, Ireland
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Cullinan S, O'Mahony D, Fleming A, Byrne S. A meta-synthesis of potentially inappropriate prescribing in older patients. Drugs Aging 2015; 31:631-8. [PMID: 24923385 DOI: 10.1007/s40266-014-0190-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Potentially inappropriate prescribing (PIP) is commonly seen amongst the older population in all clinical settings, as indicated by several prevalence studies in several countries. Quantitative work such as this confirms that this is a global public health problem likely to grow in tandem with ageing of the global population. However, less attention has been focused on why it is happening and how it can be prevented. OBJECTIVE The objective of this paper is to synthesise qualitative studies that explore PIP in older patients, in an effort to understand why it happens from a prescriber's perspective and to generate a new theory to guide future interventional studies aimed at minimising it in older people. To date, there is no published systematic synthesis of this type. METHODS Papers were deemed suitable for inclusion if they used qualitative methods, explored some area of PIP in patients over 65 years of age, were published in English and had available published abstracts. Four databases were systematically searched for papers published up to the end of April 2013: PubMed, Embase, CINAHL and Web of Knowledge. No date restrictions were applied. Key words searched were: Qualitative AND (Inappropriate* OR Appropriate* OR Safe) AND (Elderly OR Aged OR Geriatric* OR Old*) AND Prescri*. Reference lists were then searched for other suitable papers. Critical Appraisal Skills Programme criteria were used to assess quality. Meta-ethnography was used to synthesise the papers. RESULTS Out of 624 papers identified, seven papers were deemed relevant. Four key concepts were identified as being causal factors in PIP: (1) the need to please the patient, (2) feeling of being forced to prescribe, (3) tension between prescribing experience and prescribing guidelines and (4) prescriber fear. These were re-interpreted in a line of argument synthesis indicating that some doctors have self-perceived restrictions with regard to prescribing appropriately because of a combination of factors, rather than any one dominant factor. CONCLUSION Prevention of PIP may be favourably influenced by addressing the key interactive determinants of inappropriate prescribing behaviour.
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Affiliation(s)
- Shane Cullinan
- Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy Building, University College Cork, College Road, Cork, Ireland,
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Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open 2014; 4:e006544. [PMID: 25488097 PMCID: PMC4265124 DOI: 10.1136/bmjopen-2014-006544] [Citation(s) in RCA: 455] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To synthesise qualitative studies that explore prescribers' perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults. DESIGN A qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings. SETTING All healthcare settings. PARTICIPANTS Medical and non-medical prescribers of medicines to adults. OUTCOMES Prescribers' perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults. RESULTS 21 studies were included; most explored primary care physicians' perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported. CONCLUSIONS A multitude of highly interdependent factors shape prescribers' behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.
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Affiliation(s)
- Kristen Anderson
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Charming Institute, Camp Hill, Brisbane, Queensland, Australia
| | - Danielle Stowasser
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Christopher Freeman
- Charming Institute, Camp Hill, Brisbane, Queensland, Australia
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Ian Scott
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Dalleur O, Feron JM, Spinewine A. Views of general practitioners on the use of STOPP&START in primary care: a qualitative study. Acta Clin Belg 2014; 69:251-61. [PMID: 24871254 DOI: 10.1179/2295333714y.0000000036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria aim at detecting potentially inappropriate prescribing in older people. The objective was to explore general practitioners' (GPs) perceptions regarding the use of the STOPP&START tool in their practice. DESIGN We conducted three focus groups which were conveniently sampled. Vignettes with clinical cases were provided for discussion as well as a full version of the STOPP&START tool. Knowledge, strengths and weaknesses of the tool and its implementation were discussed. Two researchers independently performed content analysis, classifying quotes and creating new categories for emerging themes. RESULTS Discussions highlighted incentives (e.g. systematic procedure for medication review) and barriers (e.g. time-consuming application) influencing the use of STOPP&START in primary care. Usefulness, comprehensiveness, and relevance of the tool were also questioned. Another important category emerging from the content analysis was the projected use of the tool. The GPs imagined key elements for the implementation in daily practice: computerized clinical decision support system, education, and multidisciplinary collaborations, especially at care transitions and in nursing homes. CONCLUSION Despite variables views on the usefulness, comprehensiveness, and relevance of STOPP&START, GPs suggest the implementation of this tool in primary care within computerized clinical decision support systems, through education, and used as part of multidisciplinary collaborations.
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Bagge M, Norris P, Heydon S, Tordoff J. Older people's experiences of medicine changes on leaving hospital. Res Social Adm Pharm 2013; 10:791-800. [PMID: 24268364 DOI: 10.1016/j.sapharm.2013.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/21/2013] [Accepted: 10/21/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few qualitative studies have explored older patients' perspectives on medicine changes that resulted from a stay in hospital. OBJECTIVE To explore how older people aged ≥75 years, who had recently been discharged from hospital to their own home, understood and managed any changes to their medicines. METHODS Forty people aged ≥75 years were recruited from two internal medicine wards. Participants were included if they took four or more prescription medicines at admission, experienced a medicine change and were discharged to their own home. Participants were interviewed in person at home. Interviews were semi-structured and were recorded, transcribed verbatim, coded using NVivo, and analyzed thematically. RESULTS Participants experienced a median of four medicine changes per person and sixteen participants were unaware of the exact changes and the reasons for them. Some participants had concerns about their medicine changes. Twenty-nine participants could not recall anyone talking about their medicine changes just prior to them being discharged. The majority of participants trusted the decisions the hospital doctors made regarding their medicines and many participants spoke as if it was not their place to question doctors about their medicines. CONCLUSION Clear and understandable explanations of medicine changes are needed for older people on discharge from hospital. Health professionals should also be aware that older patients might not think it is acceptable for them to ask direct questions of staff members.
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Affiliation(s)
- Michael Bagge
- School of Pharmacy, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand.
| | - Pauline Norris
- School of Pharmacy, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand
| | - Susan Heydon
- School of Pharmacy, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand
| | - June Tordoff
- School of Pharmacy, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand
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Manias E, Kusljic S, Berry C, Brown E, Bryce E, Cliffe J, Smykowsky A. Use of the Screening Tool of Older Person's Prescriptions (STOPP) in older people admitted to an Australian hospital. Australas J Ageing 2013; 34:15-20. [PMID: 24520830 DOI: 10.1111/ajag.12054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS To determine the prevalence of potentially inappropriate medications (PIMs) in older people aged 65 years and over who were admitted to hospital, and to examine the medications and medication classes that comprised these PIMs with use of the Screening Tool of Older Person's Prescriptions. METHOD Using a retrospective clinical audit design, the medical records of 100 older patients were randomly selected and examined for the prevalence and characteristics of PIMs. The audit was undertaken of patients admitted over a 12-month period to an Australian public teaching hospital. RESULTS In total, 92 individual occurrences of PIMs were detected, and 54 patients had at least one PIM. The most common type of PIM experienced related to prescribed medications that adversely affected individuals who were prone to falls. CONCLUSION Many older patients experienced a PIM during their hospital admission, where the risk of an adverse event could outweigh the clinical benefit.
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Affiliation(s)
- Elizabeth Manias
- The University of Melbourne, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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West LM, Cordina M, Cunningham S. Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta. Pharm Pract (Granada) 2012; 10:181-7. [PMID: 24155835 PMCID: PMC3780501 DOI: 10.4321/s1886-36552012000400001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 11/07/2012] [Indexed: 12/03/2022] Open
Abstract
Appropriate prescribing remains an important priority in all medical areas of
practice. Objective The objective of this study was to apply a Medication Appropriateness Index
(MAI) to identify issues of inappropriate prescribing amongst patients
admitted from the Emergency Department (ED). Methods This study was carried out at Malta's general hospital on 125 patients
following a two-week pilot period on 10 patients. Patients aged 18 years and
over and on medication therapy were included. Medication treatment for
inappropriateness was assessed by using the MAI. Under-prescribing was also
screened for. Results Treatment charts of 125 patients, including 697 medications, were assessed
using a MAI. Overall, 115 (92%) patients had one or more medications with
one or more MAI criteria rated as inappropriate, giving a total of 384
(55.1%) medications prescribed inappropriately. The mean SD MAI score per
drug was 1.78 (SD=2.19). The most common medication classes with
appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and
anti-platelets (96.8%). The most common problems involved incorrect
directions (26%) and incorrect dosages (18.5%). There were 36 omitted
medications with untreated indications. Conclusions There is considerable inappropriate prescribing which could have significant
negative effects regarding patient care.
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Betteridge TM, Frampton CM, Jardine DL. Polypharmacy--we make it worse! A cross-sectional study from an acute admissions unit. Intern Med J 2012; 42:208-11. [PMID: 22356496 DOI: 10.1111/j.1445-5994.2011.02690.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Although polypharmacy is a major problem in the elderly, very few data have been published from Australasia. We retrospectively audited 68% of elderly patients admitted acutely to our medical unit (n= 424, mean age 80.3 ± 8 years) during a 30-day period (September, 2008). We found that long-term medications increased during hospital stay from 6.6 ± 4 to 7.7 ± 4 (P < 0.001). Adverse drug reactions were responsible for 24 admissions (5.7%). Polypharmacy is made worse by acute admission to hospital.
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Affiliation(s)
- T M Betteridge
- Department of General Medicine, Christchurch Hospital, Christchurch, New Zealand
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Gavilán-Moral E, Villafaina-Barroso A, Jiménez-de Gracia L, Gómez Santana MDC. [Polypharmacy in frail elderly patients: is deprescribing the answer?]. Rev Esp Geriatr Gerontol 2012; 47:162-167. [PMID: 22683145 DOI: 10.1016/j.regg.2012.01.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 01/21/2012] [Indexed: 06/01/2023]
Abstract
Deprescribing is the process of reconstructing multiple medication use by review and analysis and which concludes with dose modification, replacement or elimination of some drugs or adding others. Its development is intended to resolve tensions and contradictions between two sets of questions: 1/is life expectancy shorter than the time the drug takes to obtain a benefit?, and 2/are the goals of prescribing-deprescribing consistent with those of care? The validity of the rationale on deprescribing is based on scientific and ethical reasons. The usefulness and safety of many drugs that frail elderly or terminally ill takes is unknown, and other drugs may cause troublesome or severe side effects. Thus, in some cases their removal could be justified, being substantially safe doing so.
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Affiliation(s)
- Enrique Gavilán-Moral
- Servicio de Medicina de Familia, Laboratorio de Prácticas Innovadoras en Polimedicación y Salud, polimedicado.com, Plasencia, España.
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Recognition of adverse drug events in older hospitalized medical patients. Eur J Clin Pharmacol 2012; 69:75-85. [PMID: 22673927 PMCID: PMC3536996 DOI: 10.1007/s00228-012-1316-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 05/14/2012] [Indexed: 11/05/2022]
Abstract
Objective To assess medical teams’ ability to recognize adverse drug events (ADEs) in older inpatients. Methods The study cohort comprised 250 patients aged 65 years or older consecutively admitted to Internal Medicine wards of three hospitals in the Netherlands between April and November 2007. An independent expert team identified ADEs present upon admission or occurring during hospitalization by a structured retrospective patient chart review. For all ADEs identified, the expert team assessed causality, severity, preventability, and recognition by medical teams. Results The medical teams did not recognize 19.9 % of all ADEs present upon admission {60.4 ADEs [95 % confidence interval (CI) 51.5–70.8] per 100 hospitalizations} and 20.3 % of all ADEs occurring during the hospital stay [47.2 ADEs (95 % CI 39.4–56.5) per 100 hospitalizations]. Unrecognized ADEs were significantly more often ADEs with possible causality (p=0.014, df=1), ADEs caused by medication errors (p<0.001, df=1), and ADEs not manifesting as new symptoms (p<0.001, df=1). The medical teams did not recognize 23.2 % of mild to moderately severe ADEs and 16.5 % of severe, life-threatening, or fatal ADEs. The recognition of ADEs varied with event type. Conclusions The recognition of ADEs by medical teams was substantial for those ADEs with evident causality and with clinically apparent and severe consequences. ADEs mimicking underlying pathologies with a lower severity went unrecognized much more often, as did those resulting only in abnormal laboratory values. Tools to improve the recognition of ADEs by medical teams should, therefore, focus on those ADEs that are more challenging to detect.
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Delgado Silveira E, Alvarez Díaz A, Pérez Menéndez-Conde C, Muñoz García M, Cruz-Jentoft A, Bermejo Vicedo T. [Results of integrating pharmaceutical care in an Acute Geriatric Unit]. Rev Esp Geriatr Gerontol 2012; 47:49-54. [PMID: 22385587 DOI: 10.1016/j.regg.2011.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 11/14/2011] [Accepted: 11/21/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate whether the integration of pharmaceutical care in an acute geriatric unit can promote the detection of potentially inappropriate drug prescriptions (PIP) and adverse drug events (ADE), and if this can improve patient and caregiver information at hospital discharge. METHOD Descriptive prospective study in older patients admitted for acute care in the Geriatric Department of a university hospital. On admission, a pharmacist recorded a comprehensive drug history from the patient, caregiver and other available sources, and reviewed preadmission treatments in order to detect adverse drug events (using the 3(rd) Granada consensus criteria) and potentially inappropriate prescriptions (using STOPP-START criteria). At hospital discharge, the pharmacist informed patients and caregivers about the treatment and gave them computer generated written information for all drugs prescribed. RESULTS In a 9 month period 189 patients (84.7% of all admissions) were included in the pharmaceutical care program (71.9% women, mean age 87.2±5.5 years). After analysing 1523 prescriptions (mean drugs/patient 8.1±3.3), 356 (23.4%) potentially inappropriate prescriptions and 580 (38.1%) adverse drug events were detected (1.9 PIP and 3.2 ADE per patient). Almost three-quarters (74.2%) of the patients had at least one PIP: STOPP (48.9%) and START (26.9%). The most frequent adverse drug event was an untreated health problem. The pharmacist offered verbal and written information to 74.7% of the discharged patients. CONCLUSION Adding pharmaceutical care to the multidisciplinary activity of an acute geriatric care unit enables a great number of potentially inappropriate prescriptions and adverse drug events to be detected, and increases patient and caregiver information at hospital discharge.
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Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino JP, Paillaud E, Taillandier-Heriche E, Thomas C, Verny M, Pasquet B, Moutet AL, Lieberherr D, Lacaille S. A New Multimodal Geriatric Discharge-Planning Intervention to Prevent Emergency Visits and Rehospitalizations of Older Adults: The Optimization of Medication in AGEd Multicenter Randomized Controlled Trial. J Am Geriatr Soc 2011; 59:2017-28. [DOI: 10.1111/j.1532-5415.2011.03628.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | - Aurélie Lemaire
- Geriatric Unit; L'Assistance Publique-Hôpitaux de Paris; Hôpital Pitié-Salpêtrière; Paris; France
| | | | | | - Elodie Taillandier-Heriche
- Department of Geriatrics and Internal Medicine; L'Assistance Publique-Hôpitaux de Paris; Hôpital Albert Chenevier
| | - Caroline Thomas
- Geriatric Unit; L'Assistance Publique-Hôpitaux de Paris; Hôpital Saint-Antoine
| | | | - Blandine Pasquet
- Department of Epidemiology, Biostatistics, and Clinical Research; L'Assistance Publique-Hôpitaux de Paris; Hôpital Bichat
| | - Aline Lasserre Moutet
- Patient Education Unit for Chronic Patients; Hôpitaux Universitaires de Genève; Geneva; Switzerland
| | | | - Sophie Lacaille
- Geriatric Unit; L'Assistance Publique-Hôpitaux de Paris; Hôpital Bichat
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Liu W, Manias E, Gerdtz M. Understanding medication safety in healthcare settings: a critical review of conceptual models. Nurs Inq 2011; 18:290-302. [PMID: 22050615 DOI: 10.1111/j.1440-1800.2011.00541.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Understanding medication safety in healthcare settings: a critical review of conceptual models Communication can impact on the way in which medications are managed across healthcare settings. Organisational cultures and the environmental context provide an added complexity to how communication occurs in practice. The aims of this paper are: to examine six models relating to medication safety in various hospital and community settings, to consider the strengths and limitations of each model and to explore their applications to medication safety practices. The models examined for their ability to address the complexity of the medication communication process include causal models, such as the Human Error Model and the System Analysis to Clinical Incidents Model, and exploratory models, such as the Shared Decision-Making Model, the Medication Decision-Making and Management Model, the Partnership Model and the Medication Communication Model. The Medication Communication Model provides particular insights into possible interactions between aspects that influence medication safety practices. The implications of all six models for healthcare practice and future research are also discussed.
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Affiliation(s)
- Wei Liu
- The University of Melbourne, Carlton, Vic., Australia
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Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol 2011; 67:1175-88. [PMID: 21584788 DOI: 10.1007/s00228-011-1061-0] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe. METHODS Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs). RESULTS The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with >10 medications: odds ratio (OR) 7.22, 95% confidence interval (CI) 4.30-12.12, p < 0.001] and Beers' criteria (with >10 medications: OR 4.87, 95% CI 3.00-7.90, p < 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85 years significantly predicted PPOs. CONCLUSION Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.
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Knowledge of the pharmacological profile of a patient improves the quality of prescribing, the outcomes of treatment, and the utilization of health services in primary health care. Eur J Clin Pharmacol 2011; 67:1091-101. [DOI: 10.1007/s00228-011-1059-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 04/26/2011] [Indexed: 01/10/2023]
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Gallagher PF, O'Connor MN, O'Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011; 89:845-54. [PMID: 21508941 DOI: 10.1038/clpt.2011.44] [Citation(s) in RCA: 341] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Inappropriate prescribing is particularly common in older patients and is associated with adverse drug events (ADEs), hospitalization, and wasteful utilization of resources. We randomized 400 hospitalized patients aged ≥ 65 years to receive either the usual pharmaceutical care (control) or screening with STOPP/START criteria followed up with recommendations to their attending physicians (intervention). The Medication Appropriateness Index (MAI) and Assessment of Underutilization (AOU) index were used to assess prescribing appropriateness, both at the time of discharge and for 6 months after discharge. Unnecessary polypharmacy, the use of drugs at incorrect doses, and potential drug-drug and drug-disease interactions were significantly lower in the intervention group at discharge (absolute risk reduction 35.7%, number needed to screen to yield improvement in MAI = 2.8 (95% confidence interval 2.2-3.8)). Underutilization of clinically indicated medications was also reduced (absolute risk reduction 21.2%, number needed to screen to yield reduction in AOU = 4.7 (95% confidence interval 3.4-7.5)). Significant improvements in prescribing appropriateness were sustained for 6 months after discharge.
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Affiliation(s)
- P F Gallagher
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland.
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Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm 2011; 33:549-57. [PMID: 21442282 DOI: 10.1007/s11096-011-9506-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 03/14/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. SETTING Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. METHOD Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. MAIN OUTCOME MEASURES DRPs, interventions, treatment changes implemented. RESULTS Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. CONCLUSION The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.
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Affiliation(s)
- Melanie Isabelle Brulhart
- Pharmacie interjurassienne, Hospitals and Nursing homes of Jura and Jura bernois SA, Beausite 49, 2740 Moutier, Switzerland.
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Scott I, Jayathissa S. Quality of drug prescribing in older patients: is there a problem and can we improve it? Intern Med J 2011; 40:7-18. [PMID: 19712203 DOI: 10.1111/j.1445-5994.2009.02040.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.
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Affiliation(s)
- I Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
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Kraus SR, Bavendam T, Brake T, Griebling TL. Vulnerable Elderly Patients and Overactive Bladder Syndrome. Drugs Aging 2010; 27:697-713. [DOI: 10.2165/11539020-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Lesén E, Andersson K, Petzold M, Carlsten A. Socioeconomic determinants of psychotropic drug utilisation among elderly: a national population-based cross-sectional study. BMC Public Health 2010; 10:118. [PMID: 20214796 PMCID: PMC2845562 DOI: 10.1186/1471-2458-10-118] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 03/09/2010] [Indexed: 11/10/2022] Open
Abstract
Background Psychotropic drugs are commonly utilised among the elderly. This study aimed to analyse whether two socioeconomic determinants - income and marital status - are associated with differences in utilisation of psychotropic drugs and potentially inappropriate psychotropic drugs among elderly in Sweden. Methods All individuals aged 75 years and older who had purchased a psychotropic drug in Sweden during 2006 were included (68.7% women, n = 384712). Data was collected from national individual-based registers. Outcome measures were utilisation of three or more psychotropic drugs and utilisation of potentially inappropriate psychotropic drugs, as classified by the Swedish National Board of Health and Welfare. Results Individuals with low income were more likely to utilise three or more psychotropic drugs compared to those with high income; adjusted odds ratio (aOR) 1.12 (95% confidence interval [CI] 1.10-1.14). The non-married had a higher probability for utilising three or more psychotropic drugs compared to the married (aOR 1.22; CI 1.20-1.25). The highest probability was observed among the divorced and the never married. Potentially inappropriate psychotropic drugs were more common among individuals with low compared to high income (aOR 1.14; CI 1.13-1.16). Compared to the married, potentially inappropriate psychotropic drug utilisation occurred more commonly among the non-married (aOR 1.08; CI 1.06-1.10). The never married and the divorced had the highest probability. Conclusions There was an association between socioeconomic determinants and psychotropic drug utilisation. The probability for utilising potentially inappropriate psychotropics was higher among individuals with low income and among the non-married.
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Affiliation(s)
- Eva Lesén
- Nordic School of Public Health (NHV), Box 121 33, 402 42 Gothenburg, Sweden.
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