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Yew KC, Tan QR, Lim PC, Low WY, Lee CY. Assessing the impact of direct-acting antivirals on hepatitis C complications: a systematic review and meta-analysis. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:1421-1431. [PMID: 37728622 DOI: 10.1007/s00210-023-02716-x] [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: 06/26/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
Direct-acting antivirals (DAA) have become the treatment of choice for hepatitis C. Nevertheless, efficacy of DAA in preventing hepatitis C complications remains uncertain. We evaluated the impact of DAA on hepatocellular carcinoma (HCC) occurrence and recurrence, all-cause mortality, liver decompensation and liver transplantation as compared to non-DAA treated hepatitis C and the association to baseline liver status. A systematic search for articles from March 1993 to March 2022 was conducted using three electronic databases. Randomized, case-control and cohort studies with comparison to non-DAA treatment and reporting at least one outcome were included. Meta-analysis and sub-group meta-analysis based on baseline liver status were performed. Of 1497 articles retrieved, 19 studies were included, comprising of 266,310 patients (56.07% male). DAA reduced HCC occurrence significantly in non-cirrhosis (RR 0.80, 95% CI 0.69-0.92) and cirrhosis (RR 0.39, 95% CI 0.24-0.64) but not in decompensated cirrhosis. DAA treatment lowered HCC recurrence (RR 0.71, 95% CI 0.55-0.92) especially in patients with baseline HCC and waiting for liver transplant. DAA also reduced all-cause mortality (RR 0.43, 95% CI 0.23-0.78) and liver decompensation (RR 0.52, 95% CI 0.33-0.83) significantly. However, DAA did not prevent liver transplantation. The study highlighted the importance of early DAA initiation in hepatitis C treatment for benefits beyond sustained virological response. DAA therapy prevented HCC particularly in non-cirrhosis and compensated cirrhosis groups indicating benefits in preventing further worsening of liver status. Starting DAA early also reduced HCC recurrence, liver decompensation, and all-cause mortality.
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Affiliation(s)
- Kuo Chao Yew
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Quan Rui Tan
- Imperial College London-Nanyang Technological University Lee Kong Chian School of Medicine, Singapore, Singapore
- Ministry of Health Holdings Pte Ltd, Singapore, Singapore
| | - Phei Ching Lim
- Pharmacy Department, Hospital Pulau Pinang, Ministry of Health Malaysia, Georgetown, Penang, Malaysia
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Minden, Penang, Malaysia
| | - Wei Yang Low
- Imperial College London-Nanyang Technological University Lee Kong Chian School of Medicine, Singapore, Singapore
- Ministry of Health Holdings Pte Ltd, Singapore, Singapore
| | - Chong Yew Lee
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Minden, Penang, Malaysia.
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Mayer G, Zafar A, Hummel S, Landau F, Schultz JH. Individualisation, personalisation and person-centredness in mental healthcare: a scoping review of concepts and linguistic network visualisation. BMJ MENTAL HEALTH 2023; 26:e300831. [PMID: 37844963 PMCID: PMC10583082 DOI: 10.1136/bmjment-2023-300831] [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: 07/05/2023] [Accepted: 09/13/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Targeted mental health interventions are increasingly described as individualised, personalised or person-centred approaches. However, the definitions for these terms vary significantly. Their interchangeable use prevents operationalisations and measures. OBJECTIVE This scoping review provides a synthesis of key concepts, definitions and the language used in the context of these terms in an effort to delineate their use for future research. STUDY SELECTION AND ANALYSIS Our search on PubMed, EBSCO and Cochrane provided 2835 relevant titles. A total of 176 titles were found eligible for extracting data. A thematic analysis was conducted to synthesise the underlying aspects of individualisation, personalisation and person-centredness. Network visualisations of co-occurring words in 2625 abstracts were performed using VOSViewer. FINDINGS Overall, 106 out of 176 (60.2%) articles provided concepts for individualisation, personalisation and person-centredness. Studies using person-centredness provided a conceptualisation more often than the others. A thematic analysis revealed medical, psychological, sociocultural, biological, behavioural, economic and environmental dimensions of the concepts. Practical frameworks were mostly found related to person-centredness, while theoretical frameworks emerged in studies on personalisation. Word co-occurrences showed common psychiatric words in all three network visualisations, but differences in further contexts. CONCLUSIONS AND CLINICAL IMPLICATIONS The use of individualisation, personalisation and person-centredness in mental healthcare is multifaceted. While individualisation was the most generic term, personalisation was often used in biomedical or technological studies. Person-centredness emerged as the most well-defined concept, with many frameworks often related to dementia care. We recommend that the use of these terms follows a clear definition within the context of their respective disorders, treatments or medical settings. SCOPING REVIEW REGISTRATION Open Science Framework: osf.io/uatsc.
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Affiliation(s)
- Gwendolyn Mayer
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital Psychosocial Medicine Center, Heidelberg, Germany
| | - Ali Zafar
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital Psychosocial Medicine Center, Heidelberg, Germany
- Heidelberg Academy of Sciences and Humanities, Heidelberg, Germany
| | - Svenja Hummel
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital Psychosocial Medicine Center, Heidelberg, Germany
| | - Felix Landau
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital Psychosocial Medicine Center, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital Psychosocial Medicine Center, Heidelberg, Germany
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Turk A, Wong G, Mahtani KR, Maden M, Hill R, Ranson E, Wallace E, Krska J, Mangin D, Byng R, Lasserson D, Reeve J. Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 2022; 20:297. [PMID: 36042454 PMCID: PMC9429627 DOI: 10.1186/s12916-022-02475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. METHODS The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. RESULTS We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. CONCLUSION Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.
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Affiliation(s)
- Amadea Turk
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Michelle Maden
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ruaraidh Hill
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ed Ranson
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Emma Wallace
- Department of General Practice RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, L8P 1H6, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, PL4 8AA, UK
| | - Daniel Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK.
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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 PMCID: PMC9376985 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Gyllensten H, Fuller JM, Östbring MJ. Commentary: how person-centred is pharmaceutical care? Int J Clin Pharm 2021; 44:270-275. [PMID: 34562186 PMCID: PMC8866322 DOI: 10.1007/s11096-021-01332-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022]
Abstract
Health systems in many countries are currently undergoing an evolution towards more person-centred care. However, an overview of the literature shows that there is little or no guidance available on how to apply person-centred care to pharmaceutical care and clinical pharmacy practices. In this paper we apply a model for person-centred care created by a national multidisciplinary research centre in Gothenburg, Sweden, to the clinical work tasks of outpatient and inpatient pharmacists and describe how pharmaceutical care can become more person-centred.
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Affiliation(s)
- Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden. .,Centre for Person-Centred Care (GPCC), University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden.
| | - Joanne M Fuller
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden
| | - Malin Johansson Östbring
- eHealth Institute, Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden.,Pharmaceutical Department, Region Kalmar County, Kalmar, Sweden
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Why do patients struggle with their medicines?-A phenomenological hermeneutical study of how patients experience medicines in their everyday lives. PLoS One 2021; 16:e0255478. [PMID: 34358258 PMCID: PMC8345846 DOI: 10.1371/journal.pone.0255478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 07/16/2021] [Indexed: 11/19/2022] Open
Abstract
Why do so many people struggle with their medicines despite decades of research on medicines taking? Research into how people experience medicines in their everyday life remains scarce with the majority of research in this area of focusing on whether or not people take their medicines as prescribed. Hence, this study used a phenomenological hermeneutical qualitative design to gain a deeper understanding of individuals’ perspectives on the lived experience of medicine-taking. Findings from this study highlight five main themes where participants experience medicines as: 1) life-saving and indispensable, 2) normal and a daily routine, 3) confusing and concerning, 4) unsuitable without adjustment, and 5) intrusive and unwelcome. These results can be the basis for mutually agreed prescribing through a co-creative approach that aims at enhancing open and honest dialogues between patients and healthcare professionals in partnership about medicines.
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Yong YV, Mahamad Dom SH, Ahmad Sa'ad N, Lajis R, Md Yusof FA, Abdul Rahaman JA. Development and Practical Application of a Multiple-Criteria Decision Analysis Framework on Respiratory Inhalers: Is It Always Useful in the MOH Malaysia Medicines Formulary Listing Context? MDM Policy Pract 2021; 6:2381468321994063. [PMID: 33855190 PMCID: PMC8013673 DOI: 10.1177/2381468321994063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 01/18/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives. The current health technology assessment used to evaluate respiratory inhalers is associated with limitations that have necessitated the development of an explicit formulary decision-making framework to ensure balance between the accessibility, value, and affordability of medicines. This study aimed to develop a multiple-criteria decision analysis (MCDA) framework, apply the framework to potential and currently listed respiratory inhalers in the Ministry of Health Medicines Formulary (MOHMF), and analyze the impacts of applying the outputs, from the perspective of listing and delisting medicines in the formulary. Methods. The overall methodology of the framework development adhered to the recommendations of the ISPOR MCDA Emerging Good Practices Task Force. The MCDA framework was developed using Microsoft Excel 2010 and involved all relevant stakeholders. The framework was then applied to 27 medicines, based on data gathered from the highest levels of available published evidence, pharmaceutical companies, and professional opinions. The performance scores were analyzed using the additive model. The end values were then deliberated by an expert committee. Results. A total of eight main criteria and seven subcriteria were determined by the stakeholders. The economic criterion was weighted at 30%. Among the noneconomic criteria, "patient suitability" was weighted the highest. Based on the MCDA outputs, the expert committee recommended one potential medicine (out of three; 33%) be added to the MOHMF and one existing medicine (out of 24; 4%) be removed/delisted from the MOHMF. The other existing medicines remained unchanged. Conclusions. Although this framework was useful for deciding to add new medicines to the formulary, it appears to be less functional and impactful for the removal/delisting existing medicines from the MOHMF. The generalizability of this conclusion to other formulations remains to be confirmed.
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Affiliation(s)
- Yee Vern Yong
- Pharmacy Practice & Development Division, Ministry of Health Malaysia
| | | | | | - Rosliza Lajis
- National Pharmaceutical Regulatory Agency, Ministry of Health Malaysia
| | | | - Jamalul Azizi Abdul Rahaman
- Former Head of Therapeutic Drug Working Committee (TDWC) Respiratory (2014-2020), Serdang Hospital, Ministry of Health Malaysia
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Bahat G, Ilhan B, Bay I, Kilic C, Kucukdagli P, Oren MM, Karan MA. Explicit versus implicit evaluation to detect inappropriate medication use in geriatric outpatients. Aging Male 2020; 23:179-184. [PMID: 29671705 DOI: 10.1080/13685538.2018.1464552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Aim: The rates and reasons why clinicians decide not to follow recommendations from explicit-criteria have been studied scarce. We aimed to compare STOPP version 2 representing one of the most commonly used excplicit tool with the implicit comprehensive geriatric assessment mediated clinical evaluation considered as gold standard.Methods: Two hundred and six (n = 206) outpatients ≥65 years old were included. The study was designed as retrospective, cross-sectional, and randomised. STOPP version 2 criteria were systematically used to assess pre-admission treatments followed by implicit clinical evaluation regarding two questions: Were the STOPP criteria recommendations valid for the individual patient and were there any potentially inappropriate-prescription other than depicted by STOPP version 2 criteria? The underlying reason(s) and associated clinical-features were noted.Results: About 62.6% potentially inappropriate-prescriptions were identified (0.6 per-subject) according to systematic application of STOPP v2 while it was 53.4% (0.5 potentially inappropriate-prescriptions per subject) by clinician's application of STOPP v2. Prevalence of non-compliance was 14.7% in 18 (21.7%) of 83 patients identified by systematic application. Suggestion to stop a drug was not accepted because of need of treatment despite likelihood of anticipated side-effects in about 2/3 and with no-anticipated side-effects in about 1/3 of non-compliances. Not following STOPP v2 was significantly associated with lower functional level. According to clinician's implicit-evaluation, there were an extra 59.2% potentially inappropriate-prescriptions (0.6 per subject) in 80 (38.8%) patients yielding a total of 112.6% potentially inappropriate-prescription.Conclusions: Most of the STOPP v2 directed drug cessations are decided valid by the clinicians. In patients with higher functional dependency, it is likely that they are not followed due to palliation focussed care/patient-family preferences. There may be as much as STOPP v2 identified potentially inappropriate-prescriptions by implicit evaluation in a significant percent of geriatric patients signifying need for comprehensive geriatric evaluation in practice.
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Affiliation(s)
- Gulistan Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul, Turkey
| | - Birkan Ilhan
- Department of Internal Medicine, Division of Geriatrics, Dr. Ersin Arslan Training and Research Hospital, Gaziantep, Turkey
| | - Ilker Bay
- Istanbul Medical School, Department of Internal Medicine, Istanbul University, Istanbul, Turkey
| | - Cihan Kilic
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul, Turkey
| | - Pinar Kucukdagli
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul, Turkey
| | - Meryem Merve Oren
- Erzurum Provincial Health Directorate, Public Health Services Presidency, Erzurum, Turkey
| | - Mehmet Akif Karan
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul, Turkey
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Reeve J. Primary care redesign for person-centred care: delivering an international generalist revolution. Aust J Prim Health 2018; 24:PY18019. [PMID: 30099981 DOI: 10.1071/py18019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/31/2018] [Indexed: 02/28/2024]
Abstract
Person-centred primary care is a priority for patients, healthcare practitioners and health policy. Despite this, data suggest person-centred care is still not consistently achieved - and indeed, that in some areas, care may be worsening. Whole-person care is the expertise of the medical generalist - an area of clinical practice that has been neglected by health policy for some time. It is internationally recognised that there is a need to rebalance specialist and generalist primary care. Drawing on 15 years of scholarship within the science of medical generalism (the expertise of whole-person medical care), this discussion paper outlines a three-tiered approach to primary care redesign; describing changes needed at the level of the consultation, practice set up and strategic planning. The changing needs of patients living with complex chronic illness has already started a revolution in our understanding of healthcare systems. This paper outlines work to support that paradigm shift from disease-focused to person-focused primary healthcare.
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Abstract
With a growing aging population, the appropriate, effective, and safe use of medicines is a global health policy priority. One concern is patients' non-adherence to medicines, which is estimated to be up to 50%. Policymakers seek to reconfigure medicine management services and consider community pharmacy as especially well-placed to improve medicine use. In England and Wales, a commissioned medication review service called "Medicines Use Reviews (MURs)" was made available in through the National Health Service (NHS) in 2005. This involves a patient-pharmacist consultation to improve patients' knowledge and the use of medicines and to help reduce avoidable waste. However, over a decade since their introduction, questions remain over the extent to which the MUR policy has successfully been embedded in practice and translated into more effective use of medicines. The MUR intervention continues to hold many challenges ranging from poor public awareness and acceptance of MURs, organizational constraints, and issues over interprofessional collaboration. Many of these challenges are not exclusive to the MUR service, or even to the community pharmacy setting. Nevertheless, by identifying and exposing such challenges, an opportunity exists for policymakers and commissioners to seek to improve this service to patients. This narrative review explores the current challenges that face MURs. Damschroder et al's consolidated framework for implementation research is employed to help organize these challenges from patient and professional perspectives across multiple contexts. Over the past decade, MUR policy and practice has continued to evolve, being shaped by research, organizational and professional influences, and policy. Reforms to the service suggest that the MURs are becoming more responsive to patients' need and preferences. It is intended that this review will create impetus and scope for further debate, service reconfiguration, and ultimately service improvement.
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Affiliation(s)
- Asam Latif
- School of Health Sciences, Queen's Medical Centre, The University of Nottingham, Nottingham, UK,
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Reeve J, Britten N, Byng R, Fleming J, Heaton J, Krska J. Identifying enablers and barriers to individually tailored prescribing: a survey of healthcare professionals in the UK. BMC FAMILY PRACTICE 2018; 19:17. [PMID: 29334913 PMCID: PMC5769369 DOI: 10.1186/s12875-017-0705-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 12/26/2017] [Indexed: 12/05/2022]
Abstract
Background Many people now take multiple medications on a long-term basis to manage health conditions. Optimising the benefit of such polypharmacy requires tailoring of medicines use to the needs and circumstances of individuals. However, professionals report barriers to achieving this in practice. In this study, we examined health professionals’ perceptions of enablers and barriers to delivering individually tailored prescribing. Methods Normalisation Process Theory (NPT) informed an on-line survey of health professionals’ views of enablers and barriers to implementation of Individually Tailored Prescribing (ITP) of medicines. Links to the survey were sent out through known professional networks using a convenience/snowball sampling approach. Survey questions sought to identify perceptions of supports/barriers for ITP within the four domains of work described by NPT: sense making, engagement, action and monitoring. Analysis followed the framework approach developed in our previous work. Results Four hundred and nineteen responses were included in the final analysis (67.3% female, 32.7% male; 52.7% nurse prescribers, 19.8% pharmacists and 21.8% GPs). Almost half (44.9%) were experienced practitioners (16+ years in practice); around one third reported already routinely offering ITP to their patients. GPs were the group least likely to recognise this as consistent usual practice. Findings revealed general support for the principles of ITP but significant variation and inconsistency in understanding and implementation in practice. Our findings reveal four key implications for practice: the need to raise understanding of ITP as a legitimate part of professional practice; to prioritise the work of ITP within the range of individual professional activity; to improve the consistency of training and support for interpretive practice; and to review the impact of formal and informal monitoring processes on practice. Conclusion The findings will inform the ongoing development of our new complex intervention (PRIME Prescribing) to support the individual tailoring of medicines needed to address problematic polypharmacy. Electronic supplementary material The online version of this article (10.1186/s12875-017-0705-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanne Reeve
- Hull York Medical School, Hull University, Cottingham Road, HU67RX, Hull, England.
| | - Nicky Britten
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, EX1 2LU, Exeter, England
| | - Richard Byng
- Clinical Trials and Health Research, Peninsula Schools of Medicine and Dentistry, ITTC, Drake Circus, PL4 8AA, Plymouth, England
| | - Jo Fleming
- Warwick Primary Care, Warwick Medical School, University of Warwick, CV4 7AL, Coventry, England
| | - Janet Heaton
- Division of Health Research, University of the Highlands and Islands, 10 Inverness Campus, IV2 5NA, Inverness, Scotland
| | - Janet Krska
- Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Anson Building, Central Avenue, Chatham Maritime, Chatham Kent, ME4 4TB, Canada
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Ozkaynak M, Valdez R, Holden RJ, Weiss J. Infinicare framework for integrated understanding of health-related activities in clinical and daily-living contexts. Health Syst (Basingstoke) 2017; 7:66-78. [PMID: 31214339 PMCID: PMC6452830 DOI: 10.1080/20476965.2017.1390060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 12/19/2016] [Accepted: 04/21/2017] [Indexed: 10/18/2022] Open
Abstract
Clinical and consumer health informatics interventions promise to transform health care, yielding higher quality, more accessible care at a lower cost. However, the potential of these interventions cannot be achieved if they are developed and rolled out in a disconnected way: clinic-based systems typically do not interface with home-based systems that capture patient-generated health-related data. The fragmentation between these interventions severely limits the benefits of all interventions; given that health care is a continuum between clinical and daily-living settings. We introduce the Infinicare framework, which posits that clinical health-related activities "shape" daily-living-based health-related activities and, conversely, that daily-living-based health-related activities "inform" activities in clinics. Non-alignment of activities across these diverse contexts yields systemic gaps. Workflow studies that capture health-related activities and characterise gaps between clinical and daily-living contexts can inform the design and implementation of gap-filling, collaborative health information technologies. To inform these technologies, workflow studies should be patient-oriented, include both clinical and daily-living settings and subsume both process and structure variables. Novel methodologies are needed to effectively and efficiently capture health-related activities across both clinical and daily-living settings and their contexts. Guidelines for applying these recommendations in developing collaborative health information technologies are provided.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Aurora, CO, USA
| | - Rupa Valdez
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Richard J. Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing, Indianapolis, IN, USA
| | - Jason Weiss
- College of Nursing, University of Colorado-Denver, Aurora, CO, USA
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Gibson DS, Drain S, Kelly C, McGilligan V, McClean P, Atkinson SD, Murray E, McDowell A, Conway C, Watterson S, Bjourson AJ. Coincidence versus consequence: opportunities in multi-morbidity research and inflammation as a pervasive feature. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1338920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- David S. Gibson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Stephen Drain
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Catriona Kelly
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Victoria McGilligan
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Paula McClean
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Sarah D. Atkinson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Elaine Murray
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Andrew McDowell
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Caroline Conway
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Steven Watterson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Anthony J. Bjourson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
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Britten N, Moore L, Lydahl D, Naldemirci O, Elam M, Wolf A. Elaboration of the Gothenburg model of person-centred care. Health Expect 2017; 20:407-418. [PMID: 27193725 PMCID: PMC5433540 DOI: 10.1111/hex.12468] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Person-centred care (PCC) is increasingly advocated as a new way of delivering health care, but there is little evidence that it is widely practised. The University of Gothenburg Centre for Person-Centred Care (GPCC) was set up in 2010 to develop and implement person-centred care in clinical practice on the basis of three routines. These routines are based on eliciting the patient's narrative to initiate a partnership; working the partnership to achieve commonly agreed goals; and using documentation to safeguard the partnership and record the person's narrative and shared goals. OBJECTIVE In this paper, we aimed to explore professionals' understanding of PCC routines as they implement the GPCC model in a range of different settings. METHODS We conducted a qualitative study and interviewed 18 clinician-researchers from five health-care professions who were working in seven diverse GPCC projects. RESULTS Interviewees' accounts of PCC emphasized the ways in which persons are seen as different from patients; the variable emphasis placed on the person's goals; and the role of the person's own resources in building partnerships. CONCLUSION This study illustrates what is needed for health-care professionals to implement PCC in everyday practice: the recognition of the person is as important as the specific practical routines. Interviewees described the need to change the clinical mindset and to develop the ways of integrating people's narratives with clinical practice.
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Affiliation(s)
- Nicky Britten
- Institute of Health ResearchUniversity of Exeter Medical SchoolExeter
| | - Lucy Moore
- Institute of Health ResearchUniversity of Exeter Medical SchoolExeter
| | - Doris Lydahl
- Department Sociology and Work ScienceUniversity of GothenburgGothenburg
| | - Oncel Naldemirci
- Department Sociology and Work ScienceUniversity of GothenburgGothenburg
| | - Mark Elam
- Department Sociology and Work ScienceUniversity of GothenburgGothenburg
| | - Axel Wolf
- Institute of Health and Care Sciences, Sahlgrenska Academy and Centre for Person‐Centred CareUniversity of GothenburgGothenburg
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Kobue B, Moch S, Watermeyer J. "It's so hard taking pills when you don't know what they're for": a qualitative study of patients' medicine taking behaviours and conceptualisation of medicines in the context of rheumatoid arthritis. BMC Health Serv Res 2017; 17:303. [PMID: 28441949 PMCID: PMC5405531 DOI: 10.1186/s12913-017-2246-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 04/19/2017] [Indexed: 12/22/2022] Open
Abstract
Background Patients with chronic illnesses are often required to take lifelong medication to alleviate symptoms and prevent disease progression. Many patients find it difficult to adhere to prescribed medication for various reasons, some of which may link to the way they conceptualise medicines and understand their illness and treatment. This study explores the medicine taking behaviours of patients presenting with Rheumatoid Arthritis (RA), a chronic inflammatory autoimmune disease. We focused particularly on patients’ conceptualisation and understanding of medicines within this disease context, against a backdrop of scarce healthcare resources. Methods We conducted semi-structured interviews with 18 female patients at a rheumatology clinic in South Africa, as well as a review of participants’ medical records. We conducted a secondary analysis of the data using thematic analysis and framework analysis principles. Results Participants reported a range of medicine taking behaviours including self-medicating, adding complementary and alternative medicines (CAM) or traditional remedies, and sometimes acquiring prescribed medicines illegally. Participants provided insights into their understanding of what constitutes a medicine and what substances can be added to a prescribed regimen, which impacted on adherence. Importantly, the majority of participants demonstrated poor understanding of their illness, medications, regimens and dosage instructions. Conclusions Medicine taking in the context of RA, within the studied demographic, is complex and appears strongly mediated by individual and contextual factors. Poor patient understanding, individual conceptualisation of medicines and medicine taking, and the availability of a range of additional medicines and remedies impact on adherence. Based on these findings, we make some suggestions for how healthcare providers can play a greater role in educating patients living with RA about medicines, CAM and traditional remedies, as well as medicine taking behaviours.
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Affiliation(s)
- Boitshoko Kobue
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa
| | - Shirra Moch
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, and Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa.
| | - Jennifer Watermeyer
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa
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Di Paolo A, Sarkozy F, Ryll B, Siebert U. Personalized medicine in Europe: not yet personal enough? BMC Health Serv Res 2017; 17:289. [PMID: 28424057 PMCID: PMC5395930 DOI: 10.1186/s12913-017-2205-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/30/2017] [Indexed: 12/17/2022] Open
Abstract
Background Personalized medicine has the potential to allow patients to receive drugs specific to their individual disease, and to increase the efficiency of the healthcare system. There is currently no comprehensive overview of personalized medicine, and this research aims to provide an overview of the concept and definition of personalized medicine in nine European countries. Methods A targeted literature review of selected health databases and grey literature was conducted to collate information regarding the definition, process, use, funding, impact and challenges associated with personalized medicine. In-depth qualitative interviews were carried out with experts with health technology assessment, clinical provisioning, payer, academic, economic and industry experience, and with patient organizations. Results We identified a wide range of definitions of personalized medicine, with most studies referring to the use of diagnostics and individual biological information such as genetics and biomarkers. Few studies mentioned patients’ needs, beliefs, behaviour, values, wishes, utilities, environment and circumstances, and there was little evidence in the literature for formal incorporation of patient preferences into the evaluation of new medicines. Most interviewees described approaches to stratification and segmentation of patients based on genetic markers or diagnostics, and few mentioned health-related quality of life. Conclusions The published literature on personalized medicine is predominantly focused on patient stratification according to individual biological information. Although these approaches are important, incorporation of environmental factors and patients’ preferences in decision making is also needed. In future, personalized medicine should move from treating diseases to managing patients, taking into account all individual factors. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2205-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Via Roma 55, 56126, Pisa, Italy.
| | | | - Bettina Ryll
- Melanoma Patient Network Europe; Evolutionary Biology Centre, Uppsala University, Uppsala, Sweden
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria.,Area of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
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Car J, Tan WS, Huang Z, Sloot P, Franklin BD. eHealth in the future of medications management: personalisation, monitoring and adherence. BMC Med 2017; 15:73. [PMID: 28376771 PMCID: PMC5381075 DOI: 10.1186/s12916-017-0838-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/16/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Globally, healthcare systems face major challenges with medicines management and medication adherence. Medication adherence determines medication effectiveness and can be the single most effective intervention for improving health outcomes. In anticipation of growth in eHealth interventions worldwide, we explore the role of eHealth in the patients' medicines management journey in primary care, focusing on personalisation and intelligent monitoring for greater adherence. DISCUSSION eHealth offers opportunities to transform every step of the patient's medicines management journey. From booking appointments, consultation with a healthcare professional, decision-making, medication dispensing, carer support, information acquisition and monitoring, to learning about medicines and their management in daily life. It has the potential to support personalisation and monitoring and thus lead to better adherence. For some of these dimensions, such as supporting decision-making and providing reminders and prompts, evidence is stronger, but for many others more rigorous research is urgently needed. CONCLUSIONS Given the potential benefits and barriers to eHealth in medicines management, a fine balance needs to be established between evidence-based integration of technologies and constructive experimentation that could lead to a game-changing breakthrough. A concerted, transdisciplinary approach adapted to different contexts, including low- and middle-income contries is required to realise the benefits of eHealth at scale.
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Affiliation(s)
- Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 3 Fusionopolis Link, #06-13, Nexus@One-North, South tower, Singapore, 138543 Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College, London, UK
| | - Woan Shin Tan
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 3 Fusionopolis Link, #06-13, Nexus@One-North, South tower, Singapore, 138543 Singapore
- Nanyang Institute of Technology in Health and Medicine, Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore, Singapore
| | - Zhilian Huang
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, 3 Fusionopolis Link, #06-13, Nexus@One-North, South tower, Singapore, 138543 Singapore
- Nanyang Institute of Technology in Health and Medicine, Interdisciplinary Graduate School, Nanyang Technological University, Singapore, Singapore
| | - Peter Sloot
- Computational Science Laboratory, University of Amsterdam, Amsterdam, The Netherlands
- ITMO University, Saint Petersburg, Russia
- Complexity Institute, Nanyang Technological University, Singapore, Singapore
| | - Bryony Dean Franklin
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK
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Solutions to problematic polypharmacy: learning from the expertise of patients. Br J Gen Pract 2016; 65:319-20. [PMID: 26009527 DOI: 10.3399/bjgp15x685465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Beard E, Shahab L, Cummings DM, Michie S, West R. New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline? CNS Drugs 2016; 30:951-83. [PMID: 27421270 DOI: 10.1007/s40263-016-0362-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.
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Affiliation(s)
- Emma Beard
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK.
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK.
| | - Lion Shahab
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
| | - Damian M Cummings
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, WC1E 6BT, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK
| | - Robert West
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
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Reeve J, Cooper L, Harrington S, Rosbottom P, Watkins J. Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention. BMC Health Serv Res 2016; 16:470. [PMID: 27600512 PMCID: PMC5012043 DOI: 10.1186/s12913-016-1726-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 08/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health services face the challenges created by complex problems, and so need complex intervention solutions. However they also experience ongoing difficulties in translating findings from research in this area in to quality improvement changes on the ground. BounceBack was a service development innovation project which sought to examine this issue through the implementation and evaluation in a primary care setting of a novel complex intervention. METHODS The project was a collaboration between a local mental health charity, an academic unit, and GP practices. The aim was to translate the charity's model of care into practice-based evidence describing delivery and impact. Normalisation Process Theory (NPT) was used to support the implementation of the new model of primary mental health care into six GP practices. An integrated process evaluation evaluated the process and impact of care. RESULTS Implementation quickly stalled as we identified problems with the described model of care when applied in a changing and variable primary care context. The team therefore switched to using the NPT framework to support the systematic identification and modification of the components of the complex intervention: including the core components that made it distinct (the consultation approach) and the variable components (organisational issues) that made it work in practice. The extra work significantly reduced the time available for outcome evaluation. However findings demonstrated moderately successful implementation of the model and a suggestion of hypothesised changes in outcomes. CONCLUSIONS The BounceBack project demonstrates the development of a complex intervention from practice. It highlights the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention; and describes the use of the research process in the generation of practice-based evidence. Implications for future translational complex intervention research supporting practice change through scholarship are discussed.
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Affiliation(s)
- Joanne Reeve
- Warwick Medical School, Warwick University, Coventry, CV4 7AL UK
- Division of Health Sciences Research, Liverpool University, Liverpool, L69 3GL UK
- http://www2.warwick.ac.uk/fac/med/staff/jreeve
| | - Lucy Cooper
- Division of Health Sciences Research, Liverpool University, Liverpool, L69 3GL UK
| | - Sean Harrington
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
| | - Peter Rosbottom
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
| | - Jane Watkins
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
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Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study. Br J Gen Pract 2016; 66:e552-60. [PMID: 27266865 DOI: 10.3399/bjgp16x685669] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/01/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Deprescribing describes the complex process that is required for the safe and effective cessation of medications that are likely to cause more harm than benefit. Knowledgeof older adults' and carers' attitudes towards deprescribing will enhance shared decision making in medication optimisation. AIM To explore the views, beliefs, and attitudes of older adults and carers on deprescribing. DESIGN AND SETTING Qualitative focus group study in New South Wales, Australia. METHOD Four focus groups with 14 older adults and 14 carers were conducted. Results were analysed using a previously developed framework (directed content analysis) with additional conventional content analysis. RESULTS The willingness of both older adults and carers to have one or more medications deprescribed was influenced by the following main themes: their perception of the appropriateness of that medication; fear of outcomes of withdrawal; dislike of taking medications; and the availability of a process for withdrawal (including a discussion with a healthcare professional and knowing that the medication could be restarted if necessary). A patient's regular GP was identified as a strong influence both for and against medication withdrawal. The identified themes supported the previously developed framework. An additional theme unique to the carers was the complexity involved in making decisions about medications for their care recipients. CONCLUSION This study highlights that discussions between the healthcare professional and the olderadult or carer about withdrawing medications should address reasons for deprescribing. GPs should be aware of their major influence on patients and regularly discuss appropriateness of current medication use with older adults and their carers.
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Legal Aspects of Personalized Medicine. Per Med 2016. [DOI: 10.1007/978-3-319-39349-0_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lozano-Montoya I, Vélez-Diaz-Pallarés M, Delgado-Silveira E, Montero-Errasquin B, Cruz Jentoft AJ. Potentially inappropriate prescribing detected by STOPP-START criteria: are they really inappropriate? Age Ageing 2015; 44:861-6. [PMID: 26175348 DOI: 10.1093/ageing/afv079] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 03/25/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND the STOPP-START criteria were developed to detect potentially inappropriate prescribing (PIP) in older people. The reasons why multidisciplinary geriatric teams decide not to follow STOPP-START criteria have not been studied. OBJECTIVE to analyse compliance with the recommendations of the STOPP-START criteria in older inpatients. DESIGN ambispective, non-randomised study. SUBJECTS SETTING: three hundred and eighty-eight consecutive patients aged 80 years or over admitted to the acute geriatric medicine unit of a University hospital. METHODS STOPP-START criteria were systematically used by a pharmacist to assess pre-admission treatments, and the multidisciplinary geriatric team decided what drugs were recommended after discharge. Two researches independently assessed how many STOPP-START recommendations were accepted by the team, and if they were not accepted, why. RESULTS two hundred and eighty-four PIPs were identified (0.8 per subject) according to STOPP criteria. Two hundred and forty-seven of these prescriptions (87.0%) were discontinued at discharge. STOPP recommendations were not accepted in 37 cases, mostly because the team considered other therapeutic priorities (lorazepam, n = 12; risperidone, n = 5; other, n = 18). Three hundred and ninety-seven PIPs were identified according to START criteria (1.1 per subject). START recommendations were not followed at discharge in 264 cases (66.5%). The most frequent reasons were as follows: severe disability (n = 90), the use of other effective treatments for the condition (n = 38) and high risk of severe adverse effects (n = 32). Not following START criteria was significantly associated with dependency for basic activities of daily living (ADLs) (odds ratio, OR: 0.66 for compliance with a recommendation; 0.49-0.89), dependency for instrumental ADLs (OR: 0.64; 0.48-0.85) or inability to walk (OR: 0.72; 0.54-0.98). CONCLUSIONS potentially inappropriate drugs are usually discontinued, but many older hospitalised patients do not receive potentially recommended medications. More research on the reasons and consequences of this fact is needed.
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Affiliation(s)
| | | | - Eva Delgado-Silveira
- Servicio de Farmacia Hospitalaria, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Development of an Aggregated System for Classifying Causes of Drug-Related Problems. Ann Pharmacother 2015; 49:405-18. [DOI: 10.1177/1060028014568008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: More than 20 different types of classification systems for drug-related problems (DRPs) and their causes have been developed. Classification is necessary to describe and assess clinical, organizational, and economic impacts of DRPs through documentation of collected data. However, many researchers have judged classification systems incomplete when describing their data, and have modified them or developed their own. This variability between systems has made study comparisons difficult. Objectives: To perform a category-by-category comparison of the content of selected DRP classification systems to construct an aggregated cause-of-DRP classification system containing the content of all systems. Method: DRP classification systems were identified after a literature review, with 7 chosen based on their use in varied health care settings, geographical diversity, frequency of use, and method of development. These systems were critically analyzed, and the content of each category was compared and aggregated where appropriate. A hierarchy of categories was constructed to include all content from all systems. Any modifications that previous studies may have made to the 7 systems were also cross-referenced to ensure that no concepts were missing from the newly aggregated system. Clinical examples to optimize application, and instructions for when or when not to use categories, were developed. Interrater agreement for classification of the causes of DRPs from 10 medication reviews was performed between 3 clinical pharmacists and the authors’ gold standard. Results: We found variation in developmental methods, category descriptions, number and types of categories, and validation methods between the 7 selected systems, together with intermingling of categories identified as causes of DRPs with DRPs themselves. A hierarchical classification system was constructed consisting of 9 cause-of-DRP categories, 33 subcategories, and 58 sub-subcategories, for which interrater agreements were 82.5%, 74.6%, and 58.8%, respectively. Conclusion: An aggregated classification system was constructed through a unique and transparent developmental process that may provide the most comprehensive description of causes of DRPs to date. This may facilitate teaching of pharmaceutical care, comparisons of clinical practice, and measurement of the effectiveness of pharmaceutical care interventions.
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