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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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2
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Veroniki AA, Soobiah C, Nincic V, Lai Y, Rios P, MacDonald H, Khan PA, Ghassemi M, Yazdi F, Brownson RC, Chambers DA, Dolovich LR, Edwards A, Glasziou PP, Graham ID, Hemmelgarn BR, Holmes BJ, Isaranuwatchai W, Legare F, McGowan J, Presseau J, Squires JE, Stelfox HT, Strifler L, Van der Weijden T, Fahim C, Tricco AC, Straus SE. Efficacy of sustained knowledge translation (KT) interventions in chronic disease management in older adults: systematic review and meta-analysis of complex interventions. BMC Med 2023; 21:269. [PMID: 37488589 PMCID: PMC10367354 DOI: 10.1186/s12916-023-02966-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults. METHODS Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT. ELIGIBILITY CRITERIA Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care). INFORMATION SOURCES We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database's inception to March 2020. OUTCOME MEASURES Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC). Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate. DATA SYNTHESIS We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data. RESULTS We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [- 1.25, 3.47], 14 RCTs, 5876 participants, I2 = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [- 0.01, 0.02], 15 RCTs, 6628 participants, I2 = 25%; St George's Respiratory Questionnaire: MD - 2.12, 95% CI [- 3.72, - 0.51] 44 12 RCTs, 2893 participants, I2 = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I2 = 21%). CONCLUSIONS KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018084810.
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Affiliation(s)
- Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
| | - Charlene Soobiah
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
| | - Vera Nincic
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Yonda Lai
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Heather MacDonald
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Paul A. Khan
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Marco Ghassemi
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Fatemeh Yazdi
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Ross C. Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO USA
- Department of Surgery and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, 660 S. Euclid Avenue, St. Louis, MO USA
| | - David A. Chambers
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD USA
| | - Lisa R. Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada
- Department of Family Medicine David Braley Health Sciences Centre, McMaster University, 100 Main Street West, Hamilton, ON Canada
| | - Annemarie Edwards
- Canadian Partnership Against Cancer, 1 University Avenue, Toronto, ON Canada
| | - Paul P. Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD 4226 Australia
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, University of Alberta, C MacKenzie Health Sciences Centre, WalterEdmonton, AB 2J2.00 Canada
| | - Bev J. Holmes
- The Michael Smith Foundation for Health Research (MSFHR), 200 - 1285 West Broadway, Vancouver, BC Canada
| | - Wanrudee Isaranuwatchai
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - France Legare
- Département de Médecine Familiale Et Médecine d’urgenceFaculté de Médecine, Université Laval Pavillon Ferdinand-Vandry1050, Avenue de La Médecine, Local 2431, Québec, QC Canada
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec 1050, Chemin Sainte-Foy, Local K0-03, Québec, QC Canada
| | - Jessie McGowan
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON Canada
| | - Janet E. Squires
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON Canada
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
| | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, AB Canada
| | - Lisa Strifler
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Trudy Van der Weijden
- Department of Family Medicine, Maastricht University, CAPHRI Care and Public Health Research Institute, Debeyeplein 1, Maastricht, The Netherlands
| | - Christine Fahim
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Andrea C. Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Epidemiology Division & Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, ON Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, ON Canada
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Drewelow E, Ritzke M, Altiner A, Icks A, Montalbo J, Kalitzkus V, Löscher S, Pashutina Y, Fleischer S, Abraham J, Thürmann P, Mann NK, Wiese B, Wilm S, Wollny A, Feldmeier G, Buuck T, Mortsiefer A. Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home. PEC INNOVATION 2022; 1:100032. [PMID: 37213749 PMCID: PMC10194292 DOI: 10.1016/j.pecinn.2022.100032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/03/2022] [Accepted: 03/19/2022] [Indexed: 05/23/2023]
Abstract
Objectives For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Methods Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. Results A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. Conclusion The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Innovation Adapting family conferences to primary care for frail patients with polypharmacy.
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Affiliation(s)
- E. Drewelow
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
- Corresponding author at: Institut für Allgemeinmedizin, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, DE, Germany.
| | - M. Ritzke
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Altiner
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - J. Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - V. Kalitzkus
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Y. Pashutina
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Fleischer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - J. Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - P. Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - NK. Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - B. Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - S. Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - A. Wollny
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - G. Feldmeier
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - T. Buuck
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Mortsiefer
- Institute of General Practice and Primary Care, Faculty of Health, Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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Turk A, Wong G, Mahtani KR, Maden M, Hill R, Ranson E, Wallace E, Krska J, Mangin D, Byng R, Lasserson D, Reeve J. Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 2022; 20:297. [PMID: 36042454 PMCID: PMC9429627 DOI: 10.1186/s12916-022-02475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. METHODS The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. RESULTS We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. CONCLUSION Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.
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Affiliation(s)
- Amadea Turk
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Michelle Maden
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ruaraidh Hill
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ed Ranson
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Emma Wallace
- Department of General Practice RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, L8P 1H6, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, PL4 8AA, UK
| | - Daniel Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK.
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Barajas-Nava LA, Garduño-Espinosa J, Mireles Dorantes JM, Medina-Campos R, García-Peña MC. Models of comprehensive care for older persons with chronic diseases: a systematic review with a focus on effectiveness. BMJ Open 2022; 12:e059606. [PMID: 36170225 PMCID: PMC9362834 DOI: 10.1136/bmjopen-2021-059606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Ageing entails a variety of physiological changes that increase the risk of chronic non-communicable diseases. The prevalence of these diseases leads to an increase in the use of health services. The care models implemented by health systems should provide comprehensive long-term healthcare. We conducted this systematic review to determine whether any model of care for older persons have proven to be effective. METHODS A systematic review of literature was carried out to identify randomised clinical trials that have assessed how effective a care model for older patients with chronic diseases. A searches electronic databases such as MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials was conducted from January 1966 to January 2021. Two independent reviewers assessed the eligibility of the studies. Interventions were identified and classified according to the taxonomies developed by the Cochrane Effective Practice and Organisation of Care and Cochrane Consumers and Communication groups. RESULTS Of the 4952 bibliographic references that were screened, 577 were potentially eligible and the final sample included 25 studies that evaluated healthcare models in older people with chronic diseases. In the 25 care models, the most frequently implemented interventions were educational, and those based on the provision of healthcare. Only 22% of the outcomes of interventions were identified as being effective, whereas 21% were identified as being partially effective; thus, more than 50% of the outcomes were identified as being ineffective. CONCLUSIONS It was not possible to determine a care model as effective. The interventions implemented in the models are variable. The most effective outcomes were focused on improving the patient-healthcare professional relationship in the early stages of the intervention. The interventions addressed in the studies were similar to public health interventions as their main objectives focused on promoting health. Most studies were of low methodological quality.
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Affiliation(s)
- Leticia A Barajas-Nava
- Evidence-Based Medicine Research Unit, Hospital Infantil de México Federico Gómez (HIMFG), National Health Institute, México City, México
| | - Juan Garduño-Espinosa
- Head of the Research Office, Hospital Infantil de México Federico Gómez (HIMFG), National Health Institute, México City, México
| | | | - Raúl Medina-Campos
- Deputy Research Director, Instituto Nacional de Geriatría, México City, México
| | - M Carmen García-Peña
- Head of the Research Office, Instituto Nacional de Geriatría, México City, México
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Nkhoma KB, Cook A, Giusti A, Farrant L, Petrus R, Petersen I, Gwyther L, Venkatapuram S, Harding R. A systematic review of impact of person-centred interventions for serious physical illness in terms of outcomes and costs. BMJ Open 2022; 12:e054386. [PMID: 35831052 PMCID: PMC9280891 DOI: 10.1136/bmjopen-2021-054386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/20/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Person-centred care (PCC) is being internationally recognised as a critical attribute of high-quality healthcare. The International Alliance of Patients Organisations defines PCC as care that is focused and organised around people, rather than disease. Focusing on delivery, we aimed to review and evaluate the evidence from interventions that aimed to deliver PCC for people with serious physical illness and identify models of PCC interventions. METHODS Systematic review of literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched AMED, CINAHL, Cochrane Library, Embase, Medline, PsycINFO, using the following key concepts: patient/person-centred care, family centred care, family based care, individualised care, holistic care, serious illness, chronic illness, long-term conditions from inception to April 2022. Due to heterogeneity of interventions and populations studied, narrative synthesis was conducted. Study quality was appraised using the Joanna Briggs checklist. RESULTS We screened n=6156 papers. Seventy-two papers (reporting n=55 different studies) were retained in the review. Most of these studies (n=47) were randomised controlled trials. Our search yielded two main types of interventions: (1) studies with self-management components and (2) technology-based interventions. We synthesised findings across these two models:Self-management component: the interventions consisted of training of patients and/or caregivers or staff. Some studies reported that interventions had effect in reduction hospital admissions, improving quality of life and reducing costs of care.Technology-based interventions: consisted of mobile phone, mobile app, tablet/computer and video. Although some interventions showed improvements for self-efficacy, hospitalisations and length of stay, quality of life did not improve across most studies. DISCUSSION PCC interventions using self-management have some effects in reducing costs of care and improving quality of life. Technology-based interventions improves self-efficacy but has no effect on quality of life. However, very few studies used self-management and technology approaches. Further work is needed to identify how self-management and technology approaches can be used to manage serious illness. PROSPERO REGISTRATION NUMBER CRD42018108302.
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Affiliation(s)
- Kennedy Bashan Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
| | - Amelia Cook
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Alessandra Giusti
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Lindsay Farrant
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal College of Humanities, Durban, South Africa
| | - I Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Liz Gwyther
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | | | - Richard Harding
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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8
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Eriksen CU, Kamstrup–Larsen N, Birke H, Helding SAL, Ghith N, Andersen JS, Frølich A. Models of care for improving health-related quality of life, mental health, or mortality in persons with multimorbidity: A systematic review of randomized controlled trials. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2022; 12:26335565221134017. [PMID: 36325259 PMCID: PMC9618762 DOI: 10.1177/26335565221134017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To categorize and examine the effectiveness regarding health-related quality of life (HRQoL), mental health, and mortality of care models for persons with multimorbidity in primary care, community care, and hospitals through a systematic review. METHODS We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials up to May 2020. One author screened titles and abstracts, and to validate, a second author screened 5% of the studies. Two authors independently extracted data and assessed risk of bias using the tool by the Cochrane Effective Practice and Organisation of Care group. Study inclusion criteria were (1) participants aged ≥ 18 years with multimorbidity; (2) referred to multimorbidity or two or more specific chronic conditions in the title or abstract; (3) randomized controlled design; and (4) HRQoL, mental health, or mortality as primary outcome measures. We used the Foundation Framework to categorize the models and the PRISMA-guideline for reporting. RESULTS In this study, the first to report effectiveness of care models in patients with multimorbidity in hospital settings, we included 30 studies and 9,777 participants with multimorbidity. 12 studies were located in primary care, 9 in community care, and 9 in hospitals. HRQoL was reported as the primary outcome in 12 studies, mental health in 17 studies, and mortality in three studies-with significant improvements in 5, 14, and 2, respectively. The studies are presented according to settings. CONCLUSIONS Although 20 of the care models reported positive effects, the variations in populations, settings, model elements, and outcome measures made it difficult to conclude on which models and model elements were effective.
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Affiliation(s)
- Christian U Eriksen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Nina Kamstrup–Larsen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; AND Innovation and Research Center for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
| | - Hanne Birke
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Sofie A L Helding
- Rigshospitalet and DanTrials ApS, Juliane Marie Centre, Kobenhavn, Denmark; Zero Phase 1 Unit, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Nermin Ghith
- Research Group for Genomic Epidemiology, National Food Institute, Technical University of Denmark, Denmark
| | - John S Andersen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Anne Frølich
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; AND Innovation and Research Center for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
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9
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GP-delivered medication review of polypharmacy, deprescribing, and patient priorities in older people with multimorbidity in Irish primary care (SPPiRE Study): A cluster randomised controlled trial. PLoS Med 2022; 19:e1003862. [PMID: 34986166 PMCID: PMC8730438 DOI: 10.1371/journal.pmed.1003862] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/05/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND There is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care. METHODS AND FINDINGS We conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged ≥65 years with complex multimorbidity, defined as being prescribed ≥15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work. CONCLUSIONS The SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level. TRIAL REGISTRATION ISRCTN Registry ISRCTN12752680.
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10
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Smith SM, Wallace E, Clyne B, Boland F, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review. Syst Rev 2021; 10:271. [PMID: 34666828 PMCID: PMC8527775 DOI: 10.1186/s13643-021-01817-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/16/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Multimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review updated and narrowed the focus of a previous Cochrane review and aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care. METHODS We searched eight databases and two trials registers up to 9 September 2019. Two review authors independently screened potentially eligible titles and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health-related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative. RESULTS We included 16 RCTs with 4753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall, the certainty of the evidence was graded as low due to significant variation in study participants and interventions. CONCLUSIONS There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.
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Affiliation(s)
- Susan M. Smith
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Emma Wallace
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Fiona Boland
- Data Science Centre and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
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11
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Junius-Walker U, Viniol A, Michiels-Corsten M, Gerlach N, Donner-Banzhoff N, Schleef T. MediQuit, an Electronic Deprescribing Tool for Patients on Polypharmacy: Results of a Feasibility Study in German General Practice. Drugs Aging 2021; 38:725-733. [PMID: 34251594 PMCID: PMC8342343 DOI: 10.1007/s40266-021-00861-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Deprescribing is an important task for general practitioners (GPs) in the face of risky polypharmacy. The electronic tool "MediQuit" was developed to guide GPs and patients through a deprescribing consultation that entails a drug-selection phase, shared decision making, and advice on safe implementation. OBJECTIVES A pilot study was conducted to determine the target group of patients that is selected for consultation and to assess the impact, patient involvement, and feasibility of the tool. METHODS This was an uncontrolled pilot study. GPs from two German regions were invited to use MediQuit in consultations with a view to deprescribing one drug, if appropriate. They selected patients on the basis of broad inclusion criteria. Collected data entailed participants' characteristics, patients' medication lists, deprescribed drugs, and feasibility assessments. Patients were contacted shortly after the consultation and again after 4 weeks. RESULTS In total, 16 GPs agreed to participate, of whom ten actually performed deprescribing consultations. They selected 41 predominately older patients on excessive polypharmacy. Deprescribing was achieved in 70% of consultations in agreement with patients. Drugs deprescribed were symptom-lowering and preventive drugs (mainly anatomical therapeutic chemical classes A and C). GPs found MediQuit useful in initiating communication on this issue and enhancing deliberations for a deprescribing decision. The median consultation length was 15 min (interquartile range 10-20). At follow-up, GPs and patients infrequently disagreed on which drug(s) was discontinued, and GPs rated patient involvement higher than did patients themselves. DISCUSSION MediQuit assists in identifying concrete deprescribing opportunities, patient involvement, and shared decision making. The three-step deprescribing procedure is well-accepted once initial organizational efforts are overcome. After revision, further studies are needed to enhance the quality of evidence on acceptance and effectiveness.
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Affiliation(s)
| | - Annika Viniol
- Institute of General Practice, Marburg University, Marburg, Germany
| | | | - Navina Gerlach
- Institute of General Practice, Marburg University, Marburg, Germany
| | | | - Tanja Schleef
- Institute of General Practice, Hannover Medical School, Hannover, Germany
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12
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Ie K, Aoshima S, Yabuki T, Albert SM. A narrative review of evidence to guide deprescribing among older adults. J Gen Fam Med 2021; 22:182-196. [PMID: 34221792 PMCID: PMC8245739 DOI: 10.1002/jgf2.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/24/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022] Open
Abstract
Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.
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Affiliation(s)
- Kenya Ie
- Division of General Internal Medicine Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan.,Division of General Internal Medicine Department of Internal Medicine Kawasaki Municipal Tama Hospital Kawasaki Japan.,Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
| | | | - Taku Yabuki
- Department of Internal Medicine Tochigi Medical Center Tochigi Japan
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
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13
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Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:3323-3332. [PMID: 32820421 PMCID: PMC7661661 DOI: 10.1007/s11606-020-06089-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/29/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION PROSPERO - CRD42019132420.
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Affiliation(s)
- Hanna E Bloomfield
- Minneapolis VA Health Care System, Minneapolis, USA.
- University of Minnesota School of Medicine, Minneapolis, USA.
- Minneapolis VA Medical Center (151), 1 Veterans Drive, Minneapolis, MN, 55417, USA.
| | - Nancy Greer
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Amy M Linsky
- VA Boston Healthcare System and Boston University School of Medicine, Boston, USA
| | | | - Todd Naidl
- Minneapolis VA Health Care System, Minneapolis, USA
| | - Orly Vardeny
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Lauren McKenzie
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
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14
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Lee JQ, Ying K, Lun P, Tan KT, Ang W, Munro Y, Ding YY. Intervention elements to reduce inappropriate prescribing for older adults with multimorbidity receiving outpatient care: a scoping review. BMJ Open 2020; 10:e039543. [PMID: 32819958 PMCID: PMC7440708 DOI: 10.1136/bmjopen-2020-039543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Polypharmacy occurs in approximately 30% of older adults aged 65 years or more, particularly among those with multimorbidity. With polypharmacy, there is an associated risk of potentially inappropriate prescribing (PIP). The aims of this scoping review were to (1) identify the intervention elements that have been adopted to reduce PIP in the outpatient setting and (2) determine the behaviour change wheel (BCW) intervention functions performed by each of the identified intervention elements. DESIGN Scoping review DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science and Cochrane Library databases, grey literature sources, six key geriatrics journals and the reference lists of review papers. STUDY SELECTION All studies reporting an intervention or strategy that addressed PIP in the older adult population (age ≥65) with multimorbidity in the outpatient setting and in which the primary prescriber is the physician. DATA EXTRACTION Data extracted from the included studies can be broadly categorised into (1) publication details, (2) intervention details and (3) results. This was followed by data synthesis and analysis based on the BCW framework. RESULTS Of 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: 'education', 'persuasion', 'training', 'environmental restructuring' and 'enablement'. CONCLUSION PIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.
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Affiliation(s)
- Jia Qi Lee
- Geriatric Education and Research Institute, Singapore
| | - Kate Ying
- Geriatric Education and Research Institute, Singapore
| | - Penny Lun
- Geriatric Education and Research Institute, Singapore
| | - Keng Teng Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Wendy Ang
- Department of Pharmacy, Changi General Hospital, Singapore
| | - Yasmin Munro
- Medical Library, Lee Kong Chian School of Medicine, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute, Singapore
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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15
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Zhang Y, Pi B, Xu X, Li Y, Chen X, Yang N. Influence Of Narrative Medicine-Based Health Education Combined With An Online Patient Mutual Assistance Group On The Health Of Patients With Inflammatory Bowel Disease and Arthritis. Psychol Res Behav Manag 2020; 13:1-10. [PMID: 32021504 PMCID: PMC6954847 DOI: 10.2147/prbm.s213587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Inflammatory bowel disease arthritis (IBDA) threatens patients' physical and mental health. Therefore, patients need not only physical therapy, but also adequate health education and psychological support. This study was designed to explore the effect of health education based on narrative medicine combined with an online patient mutual assistance group that was based on the physical and mental health of patients with IBDA. Methods A total of 120 patients with IBDA were randomly divided into four groups (30 patients per group). Patients in the control group were given routine health education on the premise of routine treatment. The three treatment groups were given health education based on narrative medicine, online patient mutual assistance group intervention, or combined intervention. Depression, sleep, arthralgia, irritable bowel syndrome (IBS) symptoms, and inflammatory factors were measured and compared before and 1 month after the intervention. Results Before the intervention, no significant differences were observed in baseline data between the four groups. However, after the intervention, the physical and mental health of patients who received health education based on narrative medicine or online patient mutual assistance groups was improved. Our data showed that patients in the combined intervention group experienced a better outcome. Conclusion Narrative medicine-based health education combined with an online patient mutual assistance group is beneficial to the physical and mental health of IBDA patients. Taken together, this model needs to be further deepened and popularized in clinical practice.
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Affiliation(s)
- Yin Zhang
- Department of Gastroenterology, Huiyang Sanhe Hospital, Huizhou, People's Republic of China
| | - Bin Pi
- Department of Orthopedics, Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Xianlin Xu
- Department of Gastroenterology, Huiyang Sanhe Hospital, Huizhou, People's Republic of China
| | - Ying Li
- School of Health Science, Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Xiangfan Chen
- School of Health Science, Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Ningxi Yang
- College of Humanities and Social Sciences, Harbin Engineering University, Harbin, Heilongjiang, People's Republic of China
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Sharp CN, Linder MW, Valdes R. Polypharmacy: a healthcare conundrum with a pharmacogenetic solution. Crit Rev Clin Lab Sci 2019:1-20. [PMID: 31680605 DOI: 10.1080/10408363.2019.1678568] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The use of multiple medications is growing at an alarming rate with some reports documenting an average of 12-22 prescriptions being used by individuals ≥50 years of age. The indirect consequences of polypharmacy include exacerbation of drug-drug interactions, adverse drug reactions, increased likelihood of prescribing cascades, chronic dependence, and hospitalizations - all of which have significant health and economic burden. While many practical solutions for reducing polypharmacy have been proposed, they have been met with limited efficacy. This highlights the need for a new systematic approach for fine-tuning dispensing of medications. Pharmacogenetic testing provides an empirical and scientifically rigorous approach for guiding appropriate selection of medicines, with the potential to reduce unnecessary polypharmacy while improving clinical outcomes. The goal of this review article is to provide healthcare providers with an understanding of polypharmacy, its adverse effects on the healthcare system and highlight how pharmacogenetic information can be used to avoid polypharmacy in patients.
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Affiliation(s)
- Cierra N Sharp
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Mark W Linder
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Roland Valdes
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, USA
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