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Pierson T, Arcand V, Farrell B, Gagnon CL, Leung L, McCarthy LM, Murphy AL, Persaud N, Raman-Wilms L, Silvius JL, Steinman MA, Tannenbaum C, Thompson W, Trimble J, Sadowski CA, McDonald EG. Proceedings of the Canadian Medication Appropriateness and Deprescribing Network's 2023 National Meeting. Drug Saf 2024; 47:829-839. [PMID: 38884849 DOI: 10.1007/s40264-024-01444-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Tiphaine Pierson
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Verna Arcand
- Kipohtakaw Education Centre, Alexander First Nations, Sturgeon County, AB, Canada
| | - Barbara Farrell
- Bruyėre Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
| | - Camille L Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Larry Leung
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Lisa M McCarthy
- Bruyėre Research Institute, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health and Family Department, Trillium Health Partners, Mississauga, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea L Murphy
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Nav Persaud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
| | - James L Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
- Provincial Seniors Health and Continuing Care, Alberta Health Services, Calgary, AB, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael A Steinman
- University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Emily G McDonald
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada.
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Office 3E.03, 5252 De Maisonneuve Blvd, Montreal, QC, H4A3S9, Canada.
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.
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Yana J, Moscova L, Le Breton J, Boutin E, Siess T, Clerc P, Bastuji-Garin S, Ferrat E. Prescription of benzodiazepines and Z-drugs among older patients in primary care: a French, national, cohort study. Fam Pract 2024; 41:419-425. [PMID: 36308516 DOI: 10.1093/fampra/cmac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Several characteristics of patients and/or GPs linked to BZD/ZD overprescription have been described in the general population but not among older patients in primary care. OBJECTIVES To estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription, and determine whether any GP-related factors predicted BZD/ZD overprescription in this setting. METHODS We analyzed sociodemographic and practice-related GP characteristics, and aggregated data on consultations recorded prospectively by 117 GPs in a database between 2000 and 2010. Next, we used logistic regression models to look for factors potentially associated with BZD/ZD overprescription (defined as an above-median prescription rate). RESULTS The GPs' mean age at inclusion was 47.4 (7.1), and 87.9% were male. During the study period, the median (95% confidence interval) proportion of consultations with patients aged 65 and over resulting in a BZD/ZD prescription was 21.8% (18.1-26.1) (range per GP: 5-34.1%). In a multivariable analysis, a greater number of chronic disease (OR [95% CI] = 2.10 [1.22-3.64]), a greater number of drugs prescribed per consultation (5.29 [2.72-10.28]), and shorter study participation were independently associated with BZD/ZD overprescription. CONCLUSIONS BZD/ZD overprescription was associated with a greater chronic disease burden and the number of drugs prescribed per consultation but not with any sociodemographic or practice-related GP characteristics. Targeted actions are needed to help GPs limit their prescription of BZD/ZDs to older patients with multiple comorbidities and polypharmacy.
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Affiliation(s)
- Jonathan Yana
- Univ Paris-Est Creteil, School of Medicine, Primary Care Department, F-94010 Creteil, France
- Maison de Santé pluri-professionnelle Universitaire de St-Maur des Fossés, F-94100, France
| | - Laura Moscova
- Univ Paris-Est Creteil, School of Medicine, Primary Care Department, F-94010 Creteil, France
| | - Julien Le Breton
- Univ Paris-Est Creteil, School of Medicine, Primary Care Department, F-94010 Creteil, France
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- Société Française de Médecine Générale, Issy Les Moulineaux, F-92130, France
- Centre de santé universitaire Salvador Allende, F-93120 La Courneuve, France
| | - Emmanuelle Boutin
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- APHP, Hopital Henri-Mondor, Unité de Recherche Clinique (URC Mondor), F-94000 Creteil, France
| | - Tiphaine Siess
- Univ Paris-Est Creteil, School of Medicine, Primary Care Department, F-94010 Creteil, France
| | - Pascal Clerc
- Société Française de Médecine Générale, Issy Les Moulineaux, F-92130, France
- Primary Care Department, Université de Versailles, School of Medicine, F-78000 Versailles, France
| | - Sylvie Bastuji-Garin
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- Department of Public Health, APHP, Hopital Henri-Mondor, F-94000 Creteil, France
| | - Emilie Ferrat
- Univ Paris-Est Creteil, School of Medicine, Primary Care Department, F-94010 Creteil, France
- Maison de Santé pluri-professionnelle Universitaire de St-Maur des Fossés, F-94100, France
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024:1-18. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Kassis A, Moles R, Carter S. Stakeholders' perspectives and experiences of the pharmacist's role in deprescribing in ambulatory care: A qualitative meta-synthesis. Res Social Adm Pharm 2024; 20:697-712. [PMID: 38685144 DOI: 10.1016/j.sapharm.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Deprescribing is an effective strategy to manage polypharmacy and improve patient outcomes. The notion of a potential role for pharmacists in a multidisciplinary team approach to deprescribing has been identified in quantitative and qualitative literature. However, stakeholders' perceptions of this role, and factors that may impede or facilitate the pharmacist's involvement have not been elucidated. The application in ambulatory care also requires clarification. Understanding stakeholders' views is essential to optimise involvement of the pharmacist in deprescribing and improve practice. OBJECTIVES First, to synthesize the perspectives and experiences of stakeholders (primary care providers, pharmacists, patients, and carers) regarding the role and involvement of the pharmacist in deprescribing in ambulatory care settings. Second, to identify barriers and strategies to enhancing pharmacist involvement in deprescribing. METHODS A systematic search was conducted across CINAHL, Embase, Medline, and Scopus from database inception to April 2023 for qualitative studies in English exploring the pharmacist's role in deprescribing. Data were extracted for iterative and inductive development of themes. A meta-synthesis facilitated the identification of overarching themes. Qualitative secondary analysis enabled identification of barriers and facilitators to the pharmacist's involvement in deprescribing. RESULTS From 285 articles identified, 9 studies were included which explored the views of general practitioners, specialist physicians, pharmacists, nurse practitioners, patients, carers, and general practice and clinic staff as stakeholders in deprescribing in ambulatory care. The meta-synthesis identified 4 over-arching themes: (1) therapeutic impetus and the status quo mentality, (2) role and responsibility, (3) multidisciplinary care, and (4) conflicting interests in pharmacy practice. Strategies to enhance pharmacists' involvement in deprescribing emerged from the data, and the pharmacist's role was strongly encouraged by stakeholders despite logistical and perceptual barriers identified. CONCLUSIONS Incorporation of the strategies to enhance the pharmacist's involvement in deprescribing identified in this review is encouraged to optimise patient-centred care and improve practice.
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Affiliation(s)
- Amanda Kassis
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.
| | - Rebekah Moles
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Stephen Carter
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
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Sprake E, Kung J, Graham M, Tsuyuki R, Gibson W. Deprescribing for older adults during acute care admission: a scoping review protocol. JBI Evid Synth 2024:02174543-990000000-00330. [PMID: 39005222 DOI: 10.11124/jbies-23-00406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
OBJECTIVE The objective of this scoping review is to understand the current body of knowledge regarding deprescribing in adults aged 60 and over in acute care settings, including the deprescribing activities that are being undertaken, and the feasibility, challenges, and outcomes of the practice. INTRODUCTION Polypharmacy is prevalent amongst older adults, despite risks to patients. Much of the existing research on deprescribing has occurred in the outpatient context, with recent research emerging on the unique opportunity that acute care may provide. INCLUSION CRITERIA This review will include deprescribing in adults aged 60 and older in acute care. It will consider deprescribing occurring during inpatient admission and at the time of discharge from hospital. METHODS The JBI method for scoping reviews will guide this review. A search of MEDLINE (Ovid), Scopus, Web of Science, CINAHL (EBSCOhost), Embase (Ovid), and the Cochrane Database will be undertaken from inception to present with no language restrictions. Qualitative, quantitative, and mixed method studies, clinical practice guidelines, and opinion papers will be considered for inclusion. Systematic reviews and scoping reviews will be excluded. Google Scholar and a general Google search will be conducted for gray literature. Two reviewers will assess articles for inclusion and any disagreements will be discussed and resolved by discussion or a third reviewer, if required. Findings will be presented in the scoping review using a narrative approach with supporting quantitative data in a tabular format according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR). REVIEW REGISTRATION Open Science Framework https://osf.io/pb7aw/.
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Affiliation(s)
- Erika Sprake
- Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Janice Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Michelle Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ross Tsuyuki
- Department of Medicine, EPICORE Center, University of Alberta, Edmonton, AB, Canada
| | - William Gibson
- Division of Geriatric Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Nedin Rankovic GG, Pejcic AV, Krtinic DA, Stokanovic DS, Trajkovic HS, Jovanovic HM, Binic II, Jankovic SM. Factors associated with potentially inappropriate prescribing in elderly patients with various degrees of chronic kidney disease. Hemodial Int 2024. [PMID: 38960867 DOI: 10.1111/hdi.13171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/28/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION This study aimed to compare the prevalence of potentially inappropriately prescribed drugs in hemodialysis patients and patients with chronic kidney disease who did not require renal replacement therapy, as well as to identify risk factors associated with potentially inappropriate prescribing. METHODS The study was designed as a cross-sectional study conducted at the Department of Nephrology, Clinical Center in Nis, Serbia. The patients were divided into two groups: (1) patients on hemodialysis treatment and (2) patients with various degrees of chronic kidney disease without renal replacement therapy. The presence or absence of potentially inappropriate prescribing was determined using the 2015 AGS Beers criteria. FINDINGS The study included a total of 218 patients aged 65 years and over. The number of patients with potentially inappropriate prescribed drugs did not differ significantly (chi-square = 0.000, p = 1.000) between patients on hemodialysis (27 of 83, i.e., 32.5%) and patients with various degrees of chronic kidney disease without renal replacement therapy (44 of 135, i.e., 32.6%). Factors associated with potentially inappropriate prescribing in hemodialysis patients were the number of drugs (hazard ratio [HR] = 1.919, 95% confidence interval [CI]: 1.325-2.780) and number of comorbidities (HR = 1.743, 95% CI: 1.109-2.740). The number of drugs (HR = 1.438, 95% CI: 1.191-1.736) was the only independent factor associated with increased risk of potentially inappropriate prescribing in patients without renal replacement therapy. DISCUSSION Our study showed that potentially inappropriate prescribing is a relatively frequent phenomenon present in about a third of patients in both study groups. The number of prescribed drugs was the main factor associated with the increased risk of potentially inappropriate prescribing in both groups.
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Affiliation(s)
| | - Ana V Pejcic
- Faculty of Medical Sciences, Department of Pharmacology and Toxicology, University of Kragujevac, Kragujevac, Serbia
| | - Dane A Krtinic
- Medical Faculty, Department of Pharmacology and Toxicology, University of Nis, Nis, Serbia
- Clinic for Oncology, Clinical Center Nis, Nis, Serbia
| | - Dragana S Stokanovic
- Medical Faculty, Department of Pharmacology and Toxicology, University of Nis, Nis, Serbia
| | - Hristina S Trajkovic
- Medical Faculty, Department of Pharmacology and Toxicology, University of Nis, Nis, Serbia
| | - Hristina M Jovanovic
- Medical Faculty, Department of Pharmacology and Toxicology, University of Nis, Nis, Serbia
| | - Iva I Binic
- Clinic for Psychiatry, Clinical Center Nis, Nis, Serbia
| | - Slobodan M Jankovic
- Faculty of Medical Sciences, Department of Pharmacology and Toxicology, University of Kragujevac, Kragujevac, Serbia
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Van Leeuwen E, Maund E, Woods C, Bowers H, Christiaens T, Kendrick T. Health care professional barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord 2024; 356:616-627. [PMID: 38640978 DOI: 10.1016/j.jad.2024.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Long-term antidepressant (AD) use, much longer than recommended, is very common and can lead to potential harms. OBJECTIVE To investigate the existing literature on perspectives of health professionals (HPs) regarding long-term AD treatment, focusing on barriers and facilitators to discontinuation. METHODS A systematic review with thematic synthesis. Eight electronic databases were searched until August 2023 including MEDLINE, PubMed, Embase, PsycINFO, CINAHL, AMED, Health Management Information Consortium, and the Networked Digital Library of Theses and Dissertation. RESULTS Thirteen studies were included in the review. Of these, nine focused on general practitioner perspectives, one on psychiatrist perspectives, and three on a mix of HPs perspectives. Barriers and facilitators to discontinuing long-term ADs emerged within eight themes, ordered chronologically based on HP considerations during an AD review: perception of AD use, fears, HP role and responsibility, HPs' perception of AD discontinuation, HPs' confidence regarding their ability to manage discontinuation, perceived patient readiness to stop, support from patient's trusted people, and support from other HPs. LIMITATIONS Coding and development of subthemes and themes was performed by one researcher and further developed through discussion within the research team. CONCLUSION Deprescribing long-term ADs is a challenging concept for HPs. The review found evidence that the barriers far outweigh the facilitators with fear of relapse as a main barrier. HP education, reassurance and confidence-building is essential to increase the initiation of the discontinuation process. Further research into the perspectives of pharmacists and mental health workers is needed as well as exploring the role of trusted people.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium; Department of Public Health and Primary Care, Ghent University, Belgium.
| | - Emma Maund
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Catherine Woods
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Hannah Bowers
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
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Weir KR, Vordenberg SE, Scherer AM, Jansen J, Schoenborn N, Todd A. Exploring Different Contexts of Statin Deprescribing: A Vignette-Based Experiment with Older Adults Across Four Countries. J Gen Intern Med 2024; 39:1773-1776. [PMID: 38514582 PMCID: PMC11254881 DOI: 10.1007/s11606-024-08698-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/23/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Kristie Rebecca Weir
- Sydney School of Public Health, Menzies Centre for Health Policy & Economics, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
| | - Sarah E Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Aaron M Scherer
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Jesse Jansen
- Department of Family Medicine, Care and Public Health Research Institute (CAHRI), Faculty of Health Medicine and Life Sciences (FHML) Maastricht University, Maastricht, the Netherlands
| | | | - Adam Todd
- Newcastle University School of Pharmacy, Newcastle upon Tyne, UK
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Chua S, Todd A, Reeve E, Smith SM, Fox J, Elsisi Z, Hughes S, Husband A, Langford A, Merriman N, Harris JR, Devine B, Gray SL. Deprescribing interventions in older adults: An overview of systematic reviews. PLoS One 2024; 19:e0305215. [PMID: 38885276 PMCID: PMC11182547 DOI: 10.1371/journal.pone.0305215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults. METHODS 11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). RESULTS We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment. CONCLUSION Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020178860.
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Affiliation(s)
- Shiyun Chua
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Adam Todd
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Emily Reeve
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Susan M. Smith
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Julia Fox
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Zizi Elsisi
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Stephen Hughes
- School of Pharmacy, University of Sydney, Sydney, Australia
| | - Andrew Husband
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Aili Langford
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Niamh Merriman
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Jeffrey R. Harris
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Beth Devine
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Shelly L. Gray
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, United States of America
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Rodríguez-Ramallo H, Báez-Gutiérrez N, Villalba-Moreno Á, Jaramillo Ruiz D, Santos-Ramos B, Prado-Mel E, Sanchez-Fidalgo S. Reducing the drug burden of sedative and anticholinergic medications in older adults: a scoping review of explicit decision criteria. Arch Gerontol Geriatr 2024; 121:105365. [PMID: 38364710 DOI: 10.1016/j.archger.2024.105365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/27/2024] [Accepted: 02/04/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES To describe the extent, characteristics, and knowledge gaps regarding explicit decision criteria for deprescribing drugs with anticholinergic or sedative properties (Ach/Sed) in older adults. DESIGN Scoping review. SETTING AND PARTICIPANTS Original studies, clinical trial protocols, grey literature, and Summaries of Product Characteristics. METHODS Searches targeting explicit decision criteria for deprescribing Ach/Sed were performed across MEDLINE, EMBASE, CINAHL, and Web of Science, including trial registries (clinicaltrials.gov, ICTRP, EU-CTR, ANZCTR) for pertinent articles, study protocols. Additionally, to encompass non-traditional or 'grey literature' sources, Google searches and relevant agency websites were explored, alongside the summary of product characteristics for Ach/Sed. RESULTS The initial literature search identified 8,192 unique data sources. After review, 188 original articles or books, 79 internet sources, and 127 SmPCs were included. Examining these sources for explicit criteria for 154 Ach/Sed, overall, 1,271 explicit criteria guidance for identifying clinical scenarios warranting deprescription of Ach/Sed across 145/154 Ach/Sed were identified. These criteria were identified mainly from qualitative research and Summaries of Product Characteristics. Additionally, 455 criteria-based recommendations suggesting approaches for tapering implementation across 76/154 Ach/Sed were identified, mostly from sources classified as expert opinions. Significant heterogeneity was found across the approaches for tapering Ach/Sed. CONCLUSIONS This scoping review provides a comprehensive overview of the literature providing guidance for clinical scenarios where Ach/Sed should be deprescribed and highlights the existing knowledge gaps regarding comprehensive guidance on tapering these drugs which warranties future research and development.
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Affiliation(s)
- Hector Rodríguez-Ramallo
- Pharmacy Department, Virgen del Rocío University Hospital, Seville, Spain; Clinical Unit of Pneumology and Thoracic Surgery, Institute of Biomedicine of Seville, Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | | | | | - Didiana Jaramillo Ruiz
- Pharmacy Department, Virgen del Rocío University Hospital, Seville, Spain; Andalusian Public Foundation for Health Research Management of Seville, Seville, Spain
| | | | - Elena Prado-Mel
- Pharmacy Department, Virgen del Rocío University Hospital, Seville, Spain
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Japelj N, Horvat N, Knez L, Kos M. Deprescribing: An umbrella review. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2024; 74:249-267. [PMID: 38815201 DOI: 10.2478/acph-2024-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 06/01/2024]
Abstract
This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.
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Affiliation(s)
- Nuša Japelj
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Nejc Horvat
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Lea Knez
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
- 2University Clinic Golnik 4204 Golnik, Slovenia
| | - Mitja Kos
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
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Tsang JY, Sperrin M, Blakeman T, Payne RA, Ashcroft D. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. BMJ Open 2024; 14:e081698. [PMID: 38803265 PMCID: PMC11129052 DOI: 10.1136/bmjopen-2023-081698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/11/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention. OBJECTIVES To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions. DESIGN We performed a scoping review as defined by the Joanna Briggs Institute. SETTING The focus was on primary care settings. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024. ELIGIBILITY CRITERIA We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded. EXTRACTION AND ANALYSIS We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions. RESULTS In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention. CONCLUSIONS Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.
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Affiliation(s)
- Jung Yin Tsang
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Matthew Sperrin
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Rupert A Payne
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | - Darren Ashcroft
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
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13
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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Bancks MP, Mathioudakis NN, Maruthur NM. A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications. J Gen Intern Med 2024; 39:992-1001. [PMID: 37940754 DOI: 10.1007/s11606-023-08506-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN National physician survey. PARTICIPANTS US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rabia Jalalzai
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P Bancks
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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14
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Schuster BG, Faisal S, L Gagnon C. A new curricular framework for an interprofessional approach to deprescribing: Why and how pharmacists should lead the way. Can Pharm J (Ott) 2024; 157:101-103. [PMID: 38737361 PMCID: PMC11086733 DOI: 10.1177/17151635241239924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/09/2023] [Indexed: 05/14/2024]
Affiliation(s)
| | - Sadaf Faisal
- Research Centre, Institut universitaire de gériatrie de Montréal
| | - Camille L Gagnon
- Research Centre, Institut universitaire de gériatrie de Montréal
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15
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McDonald EG, Lundby C, Thompson W, Boyd C, Farrell B, Gagnon C, Herbin J, Khuong N, Moriarty F, Pierson T, Scott S, Scott IA, Silvius J, Spinewine A, Steinman MA, Tannenbaum C, Trimble J, Turner JP, Reeve E. Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks. Expert Rev Clin Pharmacol 2024; 17:433-440. [PMID: 38739460 DOI: 10.1080/17512433.2024.2355270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology in the School of Medicine, the Center on Aging and Health, and the departments of Epidemiology and Health Policy and Management at Johns Hopkins University in Baltimore, Baltimore, MD, USA
| | - Barbara Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Jennie Herbin
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tiphaine Pierson
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian A Scott
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jim Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Provincial Seniors Health & Continuing Care, Alberta Health Services, Alberta, Canada
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group UCLouvain, Brussels, Belgium
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Cara Tannenbaum
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Johanna Trimble
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Melbourne, SA, Australia
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16
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Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
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17
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Oonk NGM, Dorresteijn LDA, te Braake E, Movig KLL, van der Palen J, Nijmeijer HW, van Kesteren ME, Bode C. Structured medication reviews in Parkinson's disease: pharmacists' views, experiences and needs - a qualitative study. Ther Adv Drug Saf 2024; 15:20420986241237071. [PMID: 38694547 PMCID: PMC11062216 DOI: 10.1177/20420986241237071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 05/04/2024] Open
Abstract
Background Executing structured medication reviews (SMRs) in primary care to optimize drug treatment is considered standard care of community pharmacists in the Netherlands. Patients with Parkinson's disease (PD) often face complex drug regimens for their symptomatic treatment and might, therefore, benefit from an SMR. However, previously, no effect of an SMR on quality of life in PD was found. In trying to improve the case management of PD, it is interesting to understand if and to what extent SMRs in PD patients are of added value in the pharmacist's opinion and what are assumed facilitating and hindering factors. Objectives To analyse the process of executing SMRs in PD patients from a community pharmacist's point of view. Design A cross-sectional, qualitative study was performed, consisting of face-to-face semi-structured in-depth interviews. Methods The interviews were conducted with community pharmacists who executed at least one SMR in PD, till data saturation was reached. Interviews were transcribed verbatim, coded and analysed thematically using an iterative approach. Results Thirteen pharmacists were interviewed. SMRs in PD were considered of added value, especially regarding patient contact and bonding, individualized care and its possible effect in the future, although PD treatment is found already well monitored in secondary care. Major constraints were time, logistics and collaboration with medical specialists. Conclusion Although community pharmacist-led SMRs are time-consuming and sometimes logistically challenging, they are of added value in primary care in general, and also in PD, of which treatment occurs mainly in secondary care. It emphasizes the pharmacist's role in PD treatment and might tackle future drug-related issues. Improvements concern multidisciplinary collaboration for optimized SMR execution and results.
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Affiliation(s)
- Nicol G. M. Oonk
- Department of Neurology, Medisch Spectrum Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
- Department of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | | | - Eline te Braake
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Kris L. L. Movig
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
- Section Cognition, Data and Education, University of Twente, Enschede, The Netherlands
| | | | | | - Christina Bode
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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19
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Murphy AL, Turner JP, Rajda M, Allen KG, Gardner DM. Prescriber Acceptability of a Direct-to-Patient Intervention for Benzodiazepine Receptor Agonist Deprescribing and Behavioural Management of Insomnia in Older Adults. Can J Aging 2024:1-9. [PMID: 38456246 DOI: 10.1017/s0714980824000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Behavioural treatments are recommended first-line for insomnia, but long-term benzodiazepine receptor agonist (BZRA) use remains common and engaging patients in a deprescribing consultation is challenging. Few deprescribing interventions directly target patients. Prescribers' support of patient-targeted interventions may facilitate their uptake. Recently assessed in the Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, Sleepwell (mysleepwell.ca) was developed as a direct-to-patient behaviour change intervention promoting BZRA deprescribing and non-pharmacological insomnia management. BZRA prescribers of YAWNS NB participants were invited to complete an online survey assessing the acceptability of Sleepwell as a direct-to-patient intervention. The survey was developed using the seven construct components of the theoretical framework of acceptability (TFA) framework. Respondents (40/250, 17.2%) indicated high acceptability, with positive responses per TFA construct averaging 32.3/40 (80.7%). Perceived as an ethical, credible, and useful tool, Sleepwell also promoted prescriber-patient BZRA deprescribing engagements (11/19, 58%). Prescribers were accepting of Sleepwell and supported its application as a direct-to-patient intervention.
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Affiliation(s)
- Andrea L Murphy
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Science, Monash University, Melbourne, Victoria, Australia
- Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada
| | - Malgorzata Rajda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
- Sleep Disorders Clinic and Laboratory, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Kathleen G Allen
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David M Gardner
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
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Lukačišinová A, Reissigová J, Ortner-Hadžiabdić M, Brkic J, Okuyan B, Volmer D, Tadić I, Modamio P, Mariño EL, Tachkov K, Liperotti R, Onder G, Finne-Soveri H, van Hout H, Howard EP, Fialová D. Prevalence, country-specific prescribing patterns and determinants of benzodiazepine use in community-residing older adults in 7 European countries. BMC Geriatr 2024; 24:240. [PMID: 38454372 PMCID: PMC10921596 DOI: 10.1186/s12877-024-04742-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 01/24/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The use of benzodiazepines (BZDs) in older population is often accompanied by drug-related complications. Inappropriate BZD use significantly alters older adults' clinical and functional status. This study compares the prevalence, prescribing patterns and factors associated with BZD use in community-dwelling older patients in 7 European countries. METHODS International, cross-sectional study was conducted in community-dwelling older adults (65 +) in the Czech Republic, Serbia, Estonia, Bulgaria, Croatia, Turkey, and Spain between Feb2019 and Mar2020. Structured and standardized questionnaire based on interRAI assessment scales was applied. Logistic regression was used to evaluate factors associated with BZD use. RESULTS Out of 2,865 older patients (mean age 73.2 years ± 6.8, 61.2% women) 14.9% were BZD users. The highest prevalence of BZD use was identified in Croatia (35.5%), Spain (33.5%) and Serbia (31.3%). The most frequently prescribed BZDs were diazepam (27.9% of 426 BZD users), alprazolam (23.7%), bromazepam (22.8%) and lorazepam (16.7%). Independent factors associated with BZD use were female gender (OR 1.58, 95%CI 1.19-2.10), hyperpolypharmacy (OR 1.97, 95%CI 1.22-3.16), anxiety (OR 4.26, 95%CI 2.86-6.38), sleeping problems (OR 4.47, 95%CI 3.38-5.92), depression (OR 1.95, 95%CI 1.29-2.95), repetitive anxious complaints (OR 1.77, 95%CI 1.29-2.42), problems with syncope (OR 1.78, 95%CI 1.03-3.06), and loss of appetite (OR 0.60, 95%CI 0.38-0.94). In comparison to Croatia, residing in other countries was associated with lower odds of BZD use (ORs varied from 0.49 (95%CI 0.32-0.75) in Spain to 0.01 (95%CI 0.00-0.03) in Turkey), excluding Serbia (OR 1.11, 95%CI 0.79-1.56). CONCLUSIONS Despite well-known negative effects, BZDs are still frequently prescribed in older outpatient population in European countries. Principles of safer geriatric prescribing and effective deprescribing strategies should be individually applied in older BZD users.
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Affiliation(s)
- Anna Lukačišinová
- Department of Social and Clinical Pharmacy - Research Group "Ageing, Polypharmacy and Changes in the Therapeutic Value of Drugs in the Aged", Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, Hradec Králové, 500 05, Czech Republic.
| | - Jindra Reissigová
- Department of Statistical Modelling, Institute of Computer Science of the Czech Academy of Sciences, Prague, Czech Republic
| | - Maja Ortner-Hadžiabdić
- Center for Applied Pharmacy, Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Jovana Brkic
- Department of Social and Clinical Pharmacy - Research Group "Ageing, Polypharmacy and Changes in the Therapeutic Value of Drugs in the Aged", Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, Hradec Králové, 500 05, Czech Republic
- Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Betul Okuyan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Daisy Volmer
- Faculty of Medicine, Institute of Pharmacy, University of Tartu, Tartu, Estonia
| | - Ivana Tadić
- Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Pilar Modamio
- Clinical Pharmacy and Pharmaceutical Care Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain
| | - Eduardo L Mariño
- Clinical Pharmacy and Pharmaceutical Care Unit, Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, Barcelona, Spain
| | | | - Rosa Liperotti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Graziano Onder
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Hein van Hout
- Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Elizabeth P Howard
- Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
- The Hinda and Arthur Marcus Institute for Aging Research (The Marcus Institute), Hebrew Senior Life, Boston, MA, USA
| | - Daniela Fialová
- Department of Social and Clinical Pharmacy - Research Group "Ageing, Polypharmacy and Changes in the Therapeutic Value of Drugs in the Aged", Faculty of Pharmacy in Hradec Králové, Charles University, Heyrovského 1203, Hradec Králové, 500 05, Czech Republic
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine in Prague, Charles University, Prague, Czech Republic
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21
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Coelho T, Rosendo I, Seiça Cardoso C. Evaluation of deprescription by general practitioners in elderly people with different levels of dependence: cross-sectional study. BMC PRIMARY CARE 2024; 25:78. [PMID: 38431577 PMCID: PMC10908147 DOI: 10.1186/s12875-024-02299-3] [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: 05/20/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Polypharmacy is easily achieved in elderly patients with multimorbidity and it is associated with a higher risk of potentially inappropriate medication use and worse health outcomes. Studies have shown that deprescription is safe, however, some barriers have been identified. The aim of this study was to analyse Portuguese General Practitioners (GP) deprescription's attitudes using clinical vignettes. METHODS Cross-sectional study using an online survey with 3 sections: demographic and professional characterization; two clinical vignettes with an elderly patient with multimorbidity and polypharmacy in which the dependency level varies; barriers and factors influencing deprescription. Frequencies, means, and standard deviations were calculated to describe the GPs. Analysis of the deprescription attitude, globally and for each drug, for each clinical vignette applying the McNeemar's test. RESULTS A sample of 396 GP was obtained with a mean age of 38 years, most of them female. A statistically significant difference (p < 0.01) was observed in deprescribing according to the patient dependency level, with more GPs (80.4% versus 75.3%) deprescribing in the most dependent patient. A statistically significant difference was found for all drugs except for antihypertensive drugs. All medications were deprescribed more often in dependent patients except for anti-dementia drugs. More than 70% of the participants considered life expectancy and quality of life as "very important" factors for deprescription and more than 90% classified the existence of guidelines and the risks and benefits of medication as "very important" or "important". In the open question, the factors most reported by the GP were those related to the patient (52,9%). CONCLUSIONS This is the largest study on this topic carried out in Portugal using clinical vignettes, with a representative sample of Portuguese GP. The level of dependence significatively influenced the deprescription attitude of Portuguese GPs. The majority of the GPs classified the quality of life, life expectancies, potential negative effects and the existence of guidelines as "very important" or "important" while deprescribing. It is important to develop and test deprescribing in real life studies to analyze if these attitudes are the same in daily practice.
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Affiliation(s)
- Tânia Coelho
- Unidade de Saúde Familiar VitaSaurium, Soure, Coimbra, Portugal.
| | - Inês Rosendo
- CINTESIS - Center for Health Technology and Services Research; Faculty of Medicine, University of Porto, Porto, Portugal
- Unidade de Saúde Familiar Coimbra Centro, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Carlos Seiça Cardoso
- Unidade de Saúde Familiar Condeixa, Condeixa, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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22
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Agosti P, D'Avanzo B, Monti I, Cortesi L, Nobili A, Tettamanti M. Development and validation of the Medical Attitudes Towards Deprescribing Questionnaire. Intern Emerg Med 2024; 19:413-422. [PMID: 38123904 DOI: 10.1007/s11739-023-03489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023]
Abstract
Polypharmacy and inappropriate prescriptions in the elderly are widely discussed themes in scientific literature. Although more and more studies showed the safety and feasibility of deprescribing strategies, these are not implemented in clinical practice. In order to measure the attitudes of Italian doctors towards deprescribing and address their awareness, experiences, difficulties in applying these strategies and potential suggestions, we aimed to develop and validate a questionnaire, the Medical Attitudes Towards Deprescribing Questionnaire (MATD-Q). Between November 2017 and October 2018 an e-mail was sent to internists, geriatricians and general practitioners, to invite them to connect to a platform and answer to the questionnaire, consisting in 38 items (with a five level score) and five questions. After 2-3 weeks, a second e-mail was sent for a second completion of the questionnaire. Test-retest reliability was assessed by means of the intraclass correlation coefficient (ICC). The correlations between items were assessed by means of Pearson linear correlation coefficients and Cronbach Alpha was used to assess internal consistency. A total of 77 questionnaires completed twice were collected. By a principal component analysis we defined a smaller set of variables (n = 12), which resulted to be representative of the 38-item questionnaire.The final version of the questionnaire we developed (MATDQ-12), after validation in other cohorts, could be a useful tool to measure the efficacy of educational interventions aimed at improving the attitude of physicians towards deprescribing strategies with the final goal to allow their implementation in clinical practice.
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Affiliation(s)
- Pasquale Agosti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Barbara D'Avanzo
- Department of Health Policy, Istituto di Ricerche Farmacologiche, Milan, Italy.
| | - Igor Monti
- Department of Health Policy, Istituto di Ricerche Farmacologiche, Milan, Italy
| | - Laura Cortesi
- Department of Clinical Epidemiology and Biostatistics, IRCCS Ca' Granda Ospedale Maggiore Policlinico Mario Negri IRCCS, Milan, Italy
| | - Alessandro Nobili
- Department of Health Policy, Istituto di Ricerche Farmacologiche, Milan, Italy
| | - Mauro Tettamanti
- Department of Health Policy, Istituto di Ricerche Farmacologiche, Milan, Italy
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23
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Ramsdale E, Mohamed M, Holmes HM, Zubkoff L, Bauer J, Norton SA, Mohile S. Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol. J Geriatr Oncol 2024; 15:101687. [PMID: 38302299 PMCID: PMC10923001 DOI: 10.1016/j.jgo.2023.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Polypharmacy is prevalent in older adults with cancer and associated with multiple adverse outcomes. A single-site, cluster-randomized clinical trial will enroll older adults with cancer and polypharmacy starting chemotherapy and will assess the effectiveness and feasibility of deprescribing interventions by comparing two arms: a pharmacist-led deprescribing intervention and a patient educational brochure. MATERIALS AND METHODS The study will be conducted in two phases. In phase I, focus groups and semi-structured individual interviews will guide adaptation of deprescribing interventions for the oncology clinic (phase Ia), and eight patients will undergo the pharmacist-led deprescribing intervention with iterative adaptations (phase Ib). In phase II, a pilot cluster-randomized trial (n = 72) will compare a pharmacist-led deprescribing intervention with a patient education brochure, with treating oncologists as the cluster. Both efficacy (relative dose intensity of planned chemotherapy, potentially inappropriate medications successfully deprescribed, chemotherapy toxicity, functional status, hospitalizations, falls, and symptoms) and implementation outcomes (barriers and facilitators) will be assessed. DISCUSSION This study is anticipated to provide pilot data to inform a nationwide randomized clinical trial of deprescribing in older adults starting cancer treatment. The cluster randomization is intended to provide an initial estimate for the intervention effect as well as oncologists' intra-class correlation coefficient. Deprescribing interventions may improve outcomes in older adults starting cancer treatment, but these interventions are understudied in this population, and it is unknown how best to implement them into oncology practice. The results of this trial will inform the design of large, randomized phase III trials of deprescribing. CLINICALTRIALS gov Identifier:NCT05046171. Date of registration: September 16, 2021.
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Affiliation(s)
- Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA.
| | - Mostafa Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, TX, USA
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Jessica Bauer
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, NY, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
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24
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Mellot M, Jawal L, Morel T, Fournier JP, Tubach F, Cadwallader JS, Christiaens A, Zerah L. Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review. J Am Med Dir Assoc 2024; 25:439-447.e18. [PMID: 38237904 DOI: 10.1016/j.jamda.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVES Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. DESIGN Systematic review of qualitative and mixed-methods studies. SETTING AND PARTICIPANTS Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings. METHODS Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW). RESULTS We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints. CONCLUSIONS AND IMPLICATIONS The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.
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Affiliation(s)
- Marion Mellot
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France
| | - Lina Jawal
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France
| | - Thomas Morel
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France
| | - Jean-Pascal Fournier
- Département de Médecine Générale, Faculté de Médecine, Nantes Université, Nantes, France; Université Tours-Nantes, INSERM, UMR U1246 SPHERE "Methods in Patient-Centered Outcomes and Health Research", Tours, France
| | - Florence Tubach
- Département de Santé Publique, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Jean-Sébastien Cadwallader
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Département de Médecine Générale, Sorbonne Université, Paris, France
| | - Antoine Christiaens
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France; Fonds de la Recherche Scientifique (FNRS), Brussels, Belgium; Clinical Pharmacy Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Lorène Zerah
- Département de gériatrie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Pitié Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), Paris, France.
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25
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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26
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Brannigan R, Hughes JE, Moriarty F, Wallace E, Kirke C, Williams D, Bennett K, Cahir C. Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions. J Clin Med 2024; 13:323. [PMID: 38256457 PMCID: PMC10816937 DOI: 10.3390/jcm13020323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital. METHODS Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy). RESULTS In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission. CONCLUSION There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.
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Affiliation(s)
- Ross Brannigan
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - John E. Hughes
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
| | - Emma Wallace
- Department of General Practice, University College Cork, T12 R229 Cork, Ireland;
| | - Ciara Kirke
- National Quality and Patient Safety Directorate at Health Service Executive, D08 W2A8 Dublin, Ireland;
| | - David Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
- Department of Geriatric and Stroke Medicine Beaumont Hospital, D05 E840 Dublin, Ireland
| | - Kathleen Bennett
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Caitriona Cahir
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
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27
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Tran HTM, Roman C, Yip G, Dooley M, Salahudeen MS, Mitra B. Influence of Potentially Inappropriate Medication Use on Older Australians' Admission to Emergency Department Short Stay. Geriatrics (Basel) 2024; 9:6. [PMID: 38247981 PMCID: PMC10801464 DOI: 10.3390/geriatrics9010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90-12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11-1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.
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Affiliation(s)
- Hoa T. M. Tran
- Department of Pharmacy and Emergency and Trauma Centre, Alfred Hospital, Melbourne, VIC 3004, Australia;
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7005, Australia
| | - Cristina Roman
- Department of Pharmacy and Emergency and Trauma Centre, Alfred Hospital, Melbourne, VIC 3004, Australia;
| | - Gary Yip
- Department of General Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Michael Dooley
- Department of Pharmacy, Alfred Hospital, Melbourne, VIC 3004, Australia;
| | - Mohammed S. Salahudeen
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7005, Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, VIC 3004, Australia;
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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28
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Boyd CM, Shetterly SM, Powers JD, Weffald LA, Green AR, Sheehan OC, Reeve E, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Maciejewski ML, Wolff JL, Kraus C, Bayliss EA. Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial. Drugs Aging 2024; 41:45-54. [PMID: 37982982 PMCID: PMC11101016 DOI: 10.1007/s40266-023-01080-y] [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: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. METHODS This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. RESULTS There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. CONCLUSIONS Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. TRIAL REGISTRATION NCT03984396. Registered on 13 June 2019.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - John D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Webber C, Milani C, Bjerre LM, Lawlor PG, Bush SH, Watt CL, Pugliese M, Knoefel F, Casey G, Momoli F, Thavorn K, Tanuseputro P. Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium. J Am Med Dir Assoc 2024; 25:130-137.e4. [PMID: 37743042 DOI: 10.1016/j.jamda.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada. DESIGN Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0). SETTING AND PARTICIPANTS LTC residents in Ontario between January 1, 2016, and December 31, 2019. METHODS We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. RESULTS The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria. CONCLUSIONS AND IMPLICATIONS This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada.
| | | | - Lise M Bjerre
- ICES, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Institut du savoir Montfort, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Pugliese
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada
| | - Frank Knoefel
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Genevieve Casey
- Division of Geriatrics, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home. J Am Med Dir Assoc 2024; 25:138-145.e6. [PMID: 37913819 PMCID: PMC10843747 DOI: 10.1016/j.jamda.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY, USA.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; University of Rochester-Home Care, University of Rochester Medical Center, Rochester, NY, USA; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, NY, USA
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Waldron C, Hughes J, Wallace E, Cahir C, Bennett K. Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review. HRB Open Res 2023; 5:53. [PMID: 38283368 PMCID: PMC10811420 DOI: 10.12688/hrbopenres.13580.2] [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] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
Background Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required.A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version.The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.
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Affiliation(s)
- Catherine Waldron
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - John Hughes
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Caitriona Cahir
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - K. Bennett
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
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Hickman E, Seawoodharry M, Gillies C, Khunti K, Seidu S. Deprescribing in cardiometabolic conditions in older patients: a systematic review. GeroScience 2023; 45:3491-3512. [PMID: 37402905 PMCID: PMC10643631 DOI: 10.1007/s11357-023-00852-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/07/2023] [Indexed: 07/06/2023] Open
Abstract
We conduct a systematic review to investigate current deprescribing practices and evaluate outcomes and adverse events with deprescribing of preventive medications in older patients with either an end-of-life designation or residing in long-term care facilities with cardiometabolic conditions. Studies were identified using a literature search of MEDLINE, EMBASE, Web of Science, clinicaltrials.gov.uk, CINAHLS, and the Cochrane Register from inception to March 2022. Studies reviewed included observational studies and randomised control trials (RCTs). Data was extracted on baseline characteristics, deprescribing rates, adverse events and outcomes, and quality of life indicators, and was discussed using a narrative approach. Thirteen studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction or tapering, or switching to an alternative medication, for at least one preventive medication. Deprescribing success rates ranged from 27 to 94.7%. The studies reported no significant changes in laboratory values or adverse outcomes but did find mixed outcomes for hospitalisations and a slight increase in mortality rates when comparing the intervention and control groups. Lack of good-quality randomised control trials suggests that deprescribing in the older population residing in long-term care facilities with cardiometabolic conditions and multimorbidity is feasible when controlled and regularly monitored by an appropriate healthcare clinician, and that the benefits outweigh the potential harm in this cohort of patients. Due to the limited evidence and the heterogeneity of studies, a meta-analysis was not performed and as such further research is required to assess the benefits of deprescribing in this patient population. Systematic review registration: PROSPERO CRD42021291061.
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Affiliation(s)
- Elizabeth Hickman
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK.
| | - Mansha Seawoodharry
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
| | - Clare Gillies
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
| | - Samuel Seidu
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4WP, UK
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O'Brien E, Walsh A, Boland F, Collins C, Harkins V, Smith SM, O'Herlihy N, Clyne B, Wallace E. GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study. BJGP Open 2023; 7:BJGPO.2023.0107. [PMID: 37442591 PMCID: PMC11176671 DOI: 10.3399/bjgpo.2023.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 06/11/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice. AIM To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance. DESIGN & SETTING This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level. METHOD A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021). RESULTS Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice. CONCLUSION GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.
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Affiliation(s)
- Emer O'Brien
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Aisling Walsh
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, School of Population Health Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Velma Harkins
- Irish College of General Practitioners, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Discipline of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | | | - Barbara Clyne
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Department of General Practice, University College Cork, Cork, Ireland
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Kelley CJ, Niznik JD, Ferreri SP, Schlusser C, Armistead LT, Hughes TD, Henage CB, Busby-Whitehead J, Roberts E. Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing. Drugs Aging 2023; 40:1113-1122. [PMID: 37792262 PMCID: PMC10768261 DOI: 10.1007/s40266-023-01071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.
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Affiliation(s)
- Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tamera D Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Ellen Roberts
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
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Akande-Sholabi W, Ajilore CO, Adebusoye LA, Fakeye TO. Attitude towards medication deprescribing among older patients attending the geriatric centre: a cross-sectional survey in Southwest Nigeria. BMJ Open 2023; 13:e078391. [PMID: 37996227 PMCID: PMC10668186 DOI: 10.1136/bmjopen-2023-078391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES This study set out to assess older people's perception of their medications, attitude towards medication use and their willingness to have medications deprescribed in a geriatric centre in Southwestern Nigeria. DESIGN AND SETTING A cross-sectional study was conducted at the Chief Tony Anenih Geriatric Centre, University of Ibadan, using an interviewer-administered questionnaire. The questionnaire used was a revised version of the Patient's Attitude Towards Deprescribing Questionnaire. Descriptive statistics, and multivariate and bivariate analyses were performed using SPSS V.23. Statistical significance was set at p<0.05. PARTICIPANTS 415 older patients aged ≥60 years who attended the geriatric centre in University College Hospital Ibadan between April and July 2022. MAIN OUTCOME MEASURE The primary outcome was the willingness of the older person to deprescribe if recommended by the physician. RESULTS The mean age of the participants was 69.6±6.4 years, and 252 (60.7%) were female. Overall, the willingness and positive attitude to medication deprescribing among respondents were 60.5% and 89.7%, respectively. Factors significantly associated with willingness to deprescribe were financial self-support (p=0.021), having no previous hospital admission (p=0.009), better-perceived quality of health relative to peers (p<0.0001), polypharmacy (p=0.003), and the domains burden of medication (p=0.007), medication appropriateness (p<0.0001), concerns about stopping medications (p<0.0001) and involvement with medications (p<0.0001). The predictive factors for improved willingness to deprescribe were direct involvement with medications (OR=2.463; 95% CI 1.501 to 4.043, p<0.0001), medication appropriateness (OR=0.462; 95% CI 0.254 to 0.838, p=0.011) and concerns about stopping medications (OR=2.031; 95% CI 1.191 to 3.463, p=0.009). CONCLUSION Participants demonstrated greater willingness to deprescribe if the physicians recommended it. Predictive factors that may influence willingness to deprescribe were direct involvement with medications, appropriateness of medication and concerns about stopping medications.
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Affiliation(s)
- Wuraola Akande-Sholabi
- Department of Clinical Pharmacy and Pharmacy Administration, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Comfort Oluwatobi Ajilore
- Department of Clinical Pharmacy and Pharmacy Administration, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Lawrence A Adebusoye
- Chief Tony Anenih Geriatric Centre, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Titilayo O Fakeye
- Department of Clinical Pharmacy and Pharmacy Administration, University of Ibadan, Ibadan, Oyo, Nigeria
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Ramsdale E, Malhotra A, Holmes HM, Zubkoff L, Wang J, Mohile S, Norton SA, Duberstein PR. Emotional barriers and facilitators of deprescribing for older adults with cancer and polypharmacy: a qualitative study. Support Care Cancer 2023; 31:636. [PMID: 37847423 PMCID: PMC10581937 DOI: 10.1007/s00520-023-08084-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/26/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE To describe emotional barriers and facilitators to deprescribing (the planned reduction or discontinuation of medications) in older adults with cancer and polypharmacy. METHODS Virtual focus groups were conducted over Zoom with 5 key informant groups: oncologists, oncology nurses, primary care physicians, pharmacists, and patients. All groups were video- and audio-recorded and transcribed verbatim. Focus group transcripts were analyzed using inductive content analysis, and open coding was performed by two coders. A codebook was generated based on the initial round of open coding and updated throughout the analytic process. Codes and themes were discussed for each transcript until consensus was reached. Emotion coding (identifying text segments expressing emotion, naming the emotion, and assigning a label of positive or negative) was performed by both coders to validate the open coding findings. RESULTS All groups agreed that polypharmacy is a significant problem. For clinicians, emotional barriers to deprescribing include fear of moral judgment from patients and colleagues, frustration toward patients, and feelings of incompetence. Oncologists and patients expressed ambivalence about deprescribing due to role expectations that physicians "heal with med[ication]s." Emotional facilitators of deprescribing included the involvement of pharmacists, who were perceived to be neutral, discerning experts. Pharmacists described emotionally aware communication strategies when discussing deprescribing with other clinicians and expressed increased awareness of patient context. CONCLUSION Deprescribing can elicit strong and predominantly negative emotions among clinicians and patients which could inhibit deprescribing interventions. The involvement of pharmacists in deprescribing interventions could mitigate these emotional barriers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05046171 . Date of registration: September 16, 2021.
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Affiliation(s)
- Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA.
| | - Arul Malhotra
- James P. Wilmot Cancer Center, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, Houston, TX, USA
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinjiao Wang
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
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Hall RK, Rutledge J, Lucas A, Liu CK, Clair Russell JS, Peter WS, Fish LJ, Colón-Emeric C. Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis. Clin J Am Soc Nephrol 2023; 18:1310-1320. [PMID: 37499693 PMCID: PMC10578639 DOI: 10.2215/cjn.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics. METHODS We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020. RESULTS We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits). CONCLUSIONS Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.
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Affiliation(s)
- Rasheeda K. Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jeanette Rutledge
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anika Lucas
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Christine K. Liu
- Section of Geriatric Medicine, Stanford University School of Medicine, Stanford, California
- Geriatric Research Education and Clinical Center, Palo Alto VA Health Care System, Palo Alto, California
| | - Jennifer St. Clair Russell
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Dimensions of Care, LLC, Rockville, Maryland
| | - Wendy St. Peter
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Laura J. Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
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Huisman BAA, Geijteman ECT, Dees MK, van Zuylen L, van der Heide A, Perez RSGM. Better drug use in advanced disease: an international Delphi study. BMJ Support Palliat Care 2023; 13:e115-e121. [PMID: 30446489 PMCID: PMC10646859 DOI: 10.1136/bmjspcare-2018-001623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 11/03/2022]
Abstract
Patients with a limited life expectancy use many medications, some of which may be questionable. OBJECTIVES : To identify possible solutions for difficulties concerning medication management and formulate recommendations to improve medication management at the end of life. METHODS : A two-round Delphi study with experts in the field of medication management and end-of-life care (based on ranking in the citation index in Web of Science and relevant publications). We developed a questionnaire with 58 possible solutions for problems regarding medication management at the end of life that were identified in previously performed studies. RESULTS : A total of 42 experts from 13 countries participated. Response rate in the first round was 93%, mean agreement between experts for all solutions was 87 % (range 62%-100%); additional suggestions were given by 51%. The response rate in the second round was 74%. Awareness, education and timely communication about medication management came forward as top priorities for guidelines. In addition, solutions considered crucial by many of the experts were development of a list of inappropriate medications at the end of life and incorporation of recommendations for end-of-life medication management in disease-specific guidelines. CONCLUSIONS : In this international Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care. These findings may contribute to the development of clinical practice guidelines for medication management in end-of-life care.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne K Dees
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
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Wang J, Shen JY, Yu F, Nathan K, Caprio TV, Conwell Y, Moskow MS, Brasch JD, Simmons SF, Mixon AS, Norton SA. How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks. Clin Ther 2023; 45:947-956. [PMID: 37640614 PMCID: PMC10841554 DOI: 10.1016/j.clinthera.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC. METHODS A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping. FINDINGS Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication. IMPLICATIONS Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York.
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Kobi Nathan
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Thomas V Caprio
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; University of Rochester Home Care, University of Rochester Medical Center, Rochester, New York; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, New York
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sally A Norton
- School of Nursing, University of Rochester, Rochester, New York
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Drusch S, Zureik M, Herr M. Potentially inappropriate medications and polypharmacy in the older population: A nationwide cross-sectional study in France in 2019. Therapie 2023; 78:575-584. [PMID: 37105897 DOI: 10.1016/j.therap.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
AIM OF THE STUDY To assess the prevalence of potentially inappropriate medications (PIMs) and polypharmacy in adults aged 75 years and over in France in 2019 based on data from the French health insurance claims database, at the national level and by region. METHODS We conducted a cross-sectional study in French adults aged 75 years or over in 2019. We assessed the prevalence of seventeen PIM criteria adapted from the 2015 Beers and STOPP lists, as well as cumulative polypharmacy. Polypharmacy (5 to 9 drugs) and hyper-polypharmacy (≥10 drugs) were defined as the average number of drugs dispensed per quarter. The regional analysis used the age- and sex-standardized prevalence. RESULTS Of 6,707,897 older adults, 39.6% were exposed to at least one PIM in 2019, 46.7% were exposed to polypharmacy (5 to 9 drugs), and 25.2% to hyper-polypharmacy (≥10 drugs). Benzodiazepine PIMs were the most frequent (26.9%), followed by atropinic PIMs (8.3%), non-steroidal anti-inflammatory PIMs (7.8%), concomitant use of three or more central nervous system-active drugs (7.3%), and antihypertensive PIMs (6.0%). There was a gradient in the level of exposure to PIMs according to the level of polypharmacy for every PIM category. We observed regional variations in PIM prevalence, from 36.5% in Pays-de-la-Loire to 44.8% in Hauts-de-France in mainland France. CONCLUSION These results show that PIMs concerned more than one in three older adults after age 75 years in France in 2019 and support the need to secure medication use in this population. The reasons for geographic variations in PIM prevalence should be investigated in further studies.
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Affiliation(s)
- Solène Drusch
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), 93285 Saint-Denis Cedex, France; University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-infective Evasion and Pharmacoepidemiology, CESP, 78180 Montigny-le-Bretonneux, France.
| | - Mahmoud Zureik
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), 93285 Saint-Denis Cedex, France; University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-infective Evasion and Pharmacoepidemiology, CESP, 78180 Montigny-le-Bretonneux, France
| | - Marie Herr
- University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-infective Evasion and Pharmacoepidemiology, CESP, 78180 Montigny-le-Bretonneux, France; Epidemiology and Public Health Department, Raymond Poincaré Hospital, GHU AP-HP. University of Paris-Saclay, 92380 Garches, France
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Pariente A. Use of psychotropic drugs in the elderly in France: Are we condemned to remain at high tide? Therapie 2023; 78:565-573. [PMID: 37012150 DOI: 10.1016/j.therap.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
Psychotropics are widely used drugs, especially in the elderly, especially in France. This, and the risks associated to their use, logically led to concerns that resulted in numerous studies, reports, and regulatory actions intending to limit this use. This review objective was to provide an overview of psychotropic use in elderly subjects in France for antipsychotics, antidepressants, and benzodiazepines and related drugs. The narrative review performed is structured in two parts. The first reminds the initial steps of psychotropic use monitoring in the general French population. The second provides information on psychotropic use in elderly in France using the latest open data released by the French Health Insurance system and processed using the dedicated DrugSurv tool developed within the DRUGS-SAFE® and DRUGS-SAFE® programs. This was completed examining the most recent studies regarding psychotropic use in elderly in France, whether they consisted in publications or reports. At least before the COVID-19 epidemic, decreases in psychotropic prevalence of use among the elderly in France could be observed, mostly for antipsychotics or benzodiazepines (e.g. antipsychotics, 2006-2013: 10.3% decrease and benzodiazepines 2012-2020: decrease from 30.6% to 24.7% in subjects aged ≥65). Psychotropic prevalence of use remained however very high overall (e.g. antidepressants, 2013: 13% in subjects aged 65-74 and 18% in aged ≥65), exceeding that of most other countries, with a significant proportion of inappropriate use (e.g. in 30% of benzodiazepine users, all ages) carrying a clearly identified risks for uncertain benefit. Initiatives have been multiplied at the national level to reduce psychotropic overuse in the elderly. The reported prevalences demonstrate their effectiveness is obviously insufficient. This limited effectiveness is not specific to psychotropics and might reside in a failure to create strong adherence to messages and recommendations. Other levels should be considered, especially regional, for interventions coupled with pharmacoepidemiologic monitoring allowing impact assessment.
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Affiliation(s)
- Antoine Pariente
- Service de pharmacologie médicale, CHU de Bordeaux, université de Bordeaux, zone nord bat 1A, BP 36, 33076 Bordeaux cedex, France.
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Jamieson H, Nishtala P, Bergler HU, Weaver S, Pickering J, Ailabouni N, Abey-Nesbit R, Gullery C, Deely J, Gee S, Hilmer S, Mangin D. Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2023; 78:1692-1700. [PMID: 36692224 PMCID: PMC10460556 DOI: 10.1093/gerona/glac249] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners. METHODS Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months. RESULTS Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level. CONCLUSION Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.
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Affiliation(s)
- Hamish Jamieson
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, Centre for Therapeutic Innovation, University of Bath, Bath, UK
| | - Hans Ulrich Bergler
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Susan K Weaver
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Nagham J Ailabouni
- The Pharmacy Australian Centre of Excellence (PACE), School of Pharmacy, University of Queensland, Brisbane, Queensland, South Australia, Australia
- UniSA Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Rebecca Abey-Nesbit
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Carolyn Gullery
- Planning, Funding and Decision Support, Canterbury District Health Board, General Manager of Planning, Funding and Decision Support; Lightfoot Solutions, Healthcare Systems, Specialist Advisor, Berkshire, UK
| | - Joanne Deely
- Burwood Academy Trust, Christchurch, New Zealand
| | - Susan B Gee
- Psychiatry of Old Age Academic Unit, Canterbury District Health Board, Christchurch, New Zealand
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Dee Mangin
- Primary Care Research Group, University of Otago, Christchurch, New Zealand
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Scott S, Atkins B, Martin-Kerry JM, Pritchard M, Alldred DP, Clark AB, Colles A, Hammond A, Murphy K, Keevil VL, Kellar I, Patel M, Sims E, Taylor J, Turner D, Witham M, Wright D, Bhattacharya D. CompreHensive geriAtRician-led MEdication Review (CHARMER): protocol for a feasibility study of a hospital deprescribing behaviour change intervention. BMJ Open 2023; 13:e075795. [PMID: 37541754 PMCID: PMC10407388 DOI: 10.1136/bmjopen-2023-075795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Over 50% of older adults are prescribed a medicine where the risk of harm outweighs the chances of benefit. During a hospital admission, older adults and carers expect medicines to be reviewed for appropriateness and any inappropriate medicines proactively deprescribed. While the principle of proactive deprescribing is an expectation of good prescribing practice, it is yet to become routine. The CompreHensive geriAtRician-led MEdication Review (CHARMER) study aims to develop and test a five-component behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. This study aims to test the feasibility and acceptability of study processes and CHARMER implementation. METHODS AND ANALYSIS A two-arm purposive allocation feasibility study is being undertaken at four acute hospitals in England, UK (three intervention and one control). The target sample is 400 patients across all hospitals. Primary outcome measures are: (1) participant recruitment rate and (2) participant attrition rate. Secondary outcome measures are: (1) hospital readmission rate; (2) mortality rate and (3) quality of life. Quantitative data will be checked for completeness and quality, and practitioner and patient demographics descriptively analysed. We will undertake a rapid qualitative analysis on observations, interviews and study meeting minutes data. A subsequent thematic analysis will be undertaken with codes mapped to the Theoretical Domains Framework and Normalisation Process Theory. Triangulation of qualitative and quantitative data will be undertaken. ETHICS AND DISSEMINATION Ethics approval was obtained from Wales Research Ethics Committee 1 (IRAS ID 312494) and study approval from the Health Research Authority (22/WA/0087). Informed consent will be sought from all hospital staff involved in data collection activities and for patients involved in enhanced data collection activities. The findings of this study will be disseminated in peer-reviewed journals and conference presentations. TRIAL REGISTRATION ISRCTN11899506.
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Affiliation(s)
- Sion Scott
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Bethany Atkins
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Megan Pritchard
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Antony Colles
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amber Hammond
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Katherine Murphy
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
| | - Victoria L Keevil
- Department of Medicine for the Elderly, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ian Kellar
- Department of Psychology, The University of Sheffield, Sheffield, UK
| | - Martyn Patel
- Norwich Medical School, University of East Anglia, Norwich, UK
- Older People's Medicine Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Erika Sims
- Norwich Clinical Trials Unit, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miles Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
- AGE Research Group, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - David Wright
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
- School of Pharmacy, University of Bergen, Bergen, Norway
| | - Debi Bhattacharya
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, UK
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Gadisa DA, Gebremariam ET, Yimer G, Deresa Urgesa E. Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia. Clin Interv Aging 2023; 18:1129-1143. [PMID: 37522072 PMCID: PMC10378541 DOI: 10.2147/cia.s400698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/17/2023] [Indexed: 08/01/2023] Open
Abstract
Background Deprescribing is essential for reducing inappropriate medication use and polypharmacy. For a holistic approach, it is essential to know how older adult patients and their caregivers perceive deprescribing. Objective To assess the attitude of older adult patients and caregivers towards deprescribing medication at Ambo University Referral Hospital. Methodology Institutional-based cross-sectional study was conducted using the revised Patients' Attitude Towards Deprescribing tool (rPATD). The data was analyzed using the SPSS-25 software. Backward linear regression and logistic regression were used to measure association between outcome and determinant variables. The two-sided P-value ≤0.05 with 95% confidence interval was utilized for reporting significant factors. Results One hundred fifty-six (81.3%) of the respondents (ie, 85.0% of older adult and 77.2% of caregivers) agreed to stop one or more of their regular medications if the physician said it was possible despite 98 (51.0%) of them (ie, 49.0% of older adult and 53.3% of caregivers) being satisfied with their/their care recipient's medications. On the overall aggregate mean score, the respondents had a neutral position (2.6-3.59) regarding the burden and concerns of stopping medications whereas the majority of them disagree (1.0-2.59) with the inappropriateness of the medication they were taking and agreed (3.6-5.0) with the need for their involvement in treatment decision making. Concerns about stopping medicine scores (AOR = 0.440, 95% CI = 0.262-0.741, P = 0.035) and perceived levels of medication inappropriateness (AOR = 0.653, 95% CI = 0.456-0.936, P = 0.020) was significantly associated with the willingness to discontinue and overall satisfaction with their medicine regimen respectively. Conclusion The majority of older adult patients and caregivers would like to deprescribe if the physicians recommended it. The perceived concerns of stopping and inappropriateness of the medicines were associated with the willingness to deprescribe and overall satisfaction with their medicine respectively. Healthcare providers should prompt the deprescribing process with older adult patients and caregivers by addressing their concerns about stopping medications.
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Affiliation(s)
- Diriba Alemayehu Gadisa
- Pharmacy Department, College of Medicine and Health Sciences, Ambo University, Ambo, Oromia, Ethiopia
| | | | - Getnet Yimer
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Global Genomics & Health Equity, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Efa Deresa Urgesa
- Contract Director Management Department, Ethiopian Pharmaceutical Supply Service, Addis Ababa, Ethiopia
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Cheung S, O'Beirne M, Hill T, Huyghebaert T, Keller S, Kelly M. Management of sleep disorder by preceptors in a family medicine residency program in Calgary, Alberta: a mixed-methods study. CMAJ Open 2023; 11:E637-E644. [PMID: 37491048 PMCID: PMC10374247 DOI: 10.9778/cmajo.20220080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems. METHODS Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis. RESULTS Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management. INTERPRETATION Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.
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Affiliation(s)
- Sarah Cheung
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta
| | - Maeve O'Beirne
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta
| | - Todd Hill
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta
| | - Trudy Huyghebaert
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta
| | - Shelly Keller
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta
| | - Martina Kelly
- Department of Family Medicine (Cheung, O'Beirne, Hill, Kelly), University of Calgary; Department of Family Medicine (Huyghebaert), South Health Campus Family Medicine Teaching Clinic, University of Calgary & Alberta Health Services; Crowfoot Primary Care Network (Keller), Calgary, Alta.
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Goh SSL, Lai PSM, Ramdzan SN, Tan KM. Weighing the necessities and concerns of deprescribing among older ambulatory patients and primary care trainees: a qualitative study. BMC PRIMARY CARE 2023; 24:136. [PMID: 37391698 PMCID: PMC10311750 DOI: 10.1186/s12875-023-02084-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 06/19/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Deprescribing can be a challenging and complex process, particularly for early career doctors such as primary care trainees. To date, there is limited data from patients' and doctors' perspectives regarding the deprescribing of medications in older persons, particularly from developing countries. This study aimed to explore the necessities and concerns of deprescribing in older persons among older ambulatory patients and primary care trainees. METHODS A qualitative study was conducted among patients and primary care trainees (known henceforth as doctors). Patients aged ≥ 60 years, having ≥ 1 chronic disease and prescribed ≥ 5 medications and could communicate in either English or Malay were recruited. Doctors and patients were purposively sampled based on their stage of training as family medicine specialists and ethnicity, respectively. All interviews were audio-recorded and transcribed verbatim. A thematic approach was used to analyse data. RESULTS Twenty-four in-depth interviews (IDIs) with patients and four focus group discussions (FGDs) with 23 doctors were conducted. Four themes emerged: understanding the concept of deprescribing, the necessity to perform deprescribing, concerns regarding deprescribing and factors influencing deprescribing. Patients were receptive to the idea of deprescribing when the term was explained to them, whilst doctors had a good understanding of deprescribing. Both patients and doctors would deprescribe when the necessity outweighed their concerns. Factors that influenced deprescribing were doctor-patient rapport, health literacy among patients, external influences from carers and social media, and system challenges. CONCLUSION Deprescribing was deemed necessary by both patients and doctors when there was a reason to do so. However, both doctors and patients were afraid to deprescribe as they 'didn't want to rock the boat'. Early-career doctors were reluctant to deprescribe as they felt compelled to continue medications that were initiated by another specialist. Doctors requested more training on how to deprescribe medications.
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Affiliation(s)
- Sheron Sir Loon Goh
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
- School of Medical and Life Sciences, Sunway University, Sunway City, Selangor, 47500, Malaysia.
| | - Siti Nurkamilla Ramdzan
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kit Mun Tan
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
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Salazar A, Moreno-Pulido S, Prego-Meleiro P, Henares-Montiel J, Pulido J, Donat M, Sotres-Fernandez G, Sordo L. Correlation Between Opioid Drug Prescription and Opioid-Related Mortality in Spain as a Surveillance Tool: Ecological Study. JMIR Public Health Surveill 2023; 9:e43776. [PMID: 37379061 PMCID: PMC10365608 DOI: 10.2196/43776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/08/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Opioid drug prescription (ODP) and opioid-related mortality (ORM) have increased in Spain. However, their relationship is complex, as ORM is registered without considering the type of opioid (legal or illegal). OBJECTIVE This ecological study aimed to examine the correlation between ODP and ORM in Spain and discuss their usefulness as a surveillance tool. METHODS This was an ecological descriptive study using retrospective annual data (2000-2019) from the Spanish general population. Data were collected from people of all ages. Information on ODP was obtained from the Spanish Medicines Agency in daily doses per 1000 inhabitants per day (DHD) for total ODP, total ODP excluding those with better safety protocols (codeine and tramadol), and each opioid drug separately. Rates of ORM (per 1,000,000 inhabitants) were calculated based on deaths registered (International Classification of Diseases, 10th Revision codes) as opioid poisoning by the National Statistics Institute, derived from the drug data recorded by medical examiners in death certificates. Opioid-related deaths were considered to be those that indicated opioid consumption (accidental, infringed, or self-inflicted) as the main cause of death: death due to accidental poisoning (X40-X44), intentional self-inflicted poisoning (X60-X64), drug-induced aggression (X85), and poisoning of undetermined intention (Y10-Y14). A descriptive analysis was carried out, and correlations between the annual rates of ORM and DHD of the prescribed opioid drugs globally, excluding medications of the least potential risk of overdose and lowest treatment tier, were analyzed using Pearson linear correlation coefficient. Their temporal evolution was analyzed using cross-correlations with 24 lags and the cross-correlation function. The analyses were carried out using Stata and StatGraphics Centurion 19. RESULTS The rate of ORM (2000-2019) ranged between 14 and 23 deaths per 1,000,000 inhabitants, with a minimum in 2006 and an increasing trend starting in 2010. The ODP ranged between 1.51 to 19.94 DHD. The rates of ORM were directly correlated with the DHD of total ODP (r=0.597; P=.006), total ODP without codeine and tramadol (r=0.934; P<.001), and every prescribed opioid except buprenorphine (P=.47). In the time analysis, correlations between DHD and ORM were observed in the same year, although not statistically significant (all P≥.05). CONCLUSIONS There is a correlation between greater availability of prescribed opioid drugs and an increase in opioid-related deaths. The correlation between ODP and ORM may be a useful tool in monitoring legal opiates and possible disturbances in the illegal market. The role of tramadol (an easily prescribed opioid) is important in this correlation, as is that of fentanyl (the strongest opioid). Measures stronger than recommendations need to be taken to reduce off-label prescribing. This study shows that not only is opioid use directly related to the prescribing of opioid drugs above what is desirable but also an increase in deaths.
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Affiliation(s)
- Alejandro Salazar
- Observatory of Pain, University of Cádiz, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cádiz, Spain
- Department of Statistics and Operational Research, University of Cádiz, Puerto Real, Spain
| | | | - Pablo Prego-Meleiro
- Department of Public Health and Maternal-Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering, Faculty of Pharmacy, University of Alcalá, Alcalá de Henares, Spain
| | - Jesús Henares-Montiel
- Center for Biomedical Research in Epidemiology and Public Health (CIBER), Madrid, Spain
- Andalusian School of Public Health, Granada, Spain
| | - José Pulido
- Department of Public Health and Maternal-Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- Center for Biomedical Research in Epidemiology and Public Health (CIBER), Madrid, Spain
| | - Marta Donat
- National School of Health, Salud Carlos III Health Institute, Madrid, Spain
| | - Gabriel Sotres-Fernandez
- Oncology Department, Hospital Quirón Salud, Madrid, Spain
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Luis Sordo
- Department of Public Health and Maternal-Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- Center for Biomedical Research in Epidemiology and Public Health (CIBER), Madrid, Spain
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Henriksen BT, Krogseth M, Andersen RD, Davies MN, Nguyen CT, Mathiesen L, Andersson Y. Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial. J Orthop Surg Res 2023; 18:434. [PMID: 37312222 DOI: 10.1186/s13018-023-03906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/04/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients. METHODS Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality. RESULTS The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients). CONCLUSION The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy. TRIAL REGISTRATION NCT03695081.
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Affiliation(s)
- Ben Tore Henriksen
- Research Department, Hospital Pharmacies Enterprise, South Eastern Norway, Tonsberg, Norway.
- Division of Surgery, Vestfold Hospital Trust, Tonsberg, Norway.
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.
| | - Maria Krogseth
- Old Age Psychiatry Research Network, Telemark Vestfold, Vestfold Hospital Trust, Tonsberg, Norway
| | - Randi Dovland Andersen
- Department of Research, Telemark Hospital Trust, Skien, Norway
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maren Nordsveen Davies
- Research Department, Hospital Pharmacies Enterprise, South Eastern Norway, Tonsberg, Norway
| | - Caroline Thy Nguyen
- Research Department, Hospital Pharmacies Enterprise, South Eastern Norway, Tonsberg, Norway
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Tromso, Tromso, Norway
| | - Liv Mathiesen
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Yvonne Andersson
- Research Department, Hospital Pharmacies Enterprise, South Eastern Norway, Tonsberg, Norway
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Scott S, Atkins B, Kellar I, Taylor J, Keevil V, Alldred DP, Murphy K, Patel M, Witham MD, Wright D, Bhattacharya D. Co-design of a behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe medicines that are no longer needed or are risky to continue in hospital. Res Social Adm Pharm 2023; 19:707-716. [PMID: 36841632 DOI: 10.1016/j.sapharm.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Trials of hospital deprescribing interventions have demonstrated limited changes in practitioner behaviour. Our previous research characterised four barriers and one enabler to geriatricians and pharmacists deprescribing in hospital that require addressing by a behaviour change intervention. Six behaviour change techniques (BCTs) have also been selected by the target audience using the hospital Deprescribing Implementation Framework (hDIF). This research aimed to co-design and operationalise the content, mode of delivery and duration/intensity of the six selected BCTs to develop the CompreHensive geriAtRician-led MEdication Review (CHARMER) deprescribing intervention. METHODS We established co-design panels at three hospitals representing contextual factors likely to influence CHARMER implementation. Panels comprised geriatricians, pharmacists and other hospital staff likely to be involved in implementation. We convened two rounds of co-design workshops with each hospital to design a prototype for each BCT, which went for feedback at a final workshop attended by all three hospital panels. RESULTS The six BCTs were co-designed into an intervention comprising:(1&2) Pharmacists' workshop with pros and cons of deprescribing activities, and videos of salient patient cases3 Regular geriatrician and pharmacist deprescribing briefings4 Videos of geriatricians navigating challenging deprescribing consultations5 Hospital deprescribing action plan6 Dashboard to benchmark deprescribing activitiesAutomated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs by stakeholders. These were later excluded as they were not fidelitous to the theoretical determinants of geriatricians' and pharmacists' deprescribing behaviours. CONCLUSIONS This study illustrates the integration of theory and co-design methodology with the target audience and staff likely to be involved in implementation of a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach.
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Affiliation(s)
- Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK.
| | - Bethany Atkins
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian Kellar
- School of Psychology, University of Leeds, Leeds, UK
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Victoria Keevil
- Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Martyn Patel
- Norfolk and Norwich University Hospital, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miles D Witham
- Newcastle Biomedical Research Centre, Newcastle University, Newcastle Upon Tyne, UK
| | - David Wright
- School of Healthcare, University of Leicester, Leicester, UK; School of Pharmacy, University of Bergen, Bergen, Norway
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