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Krychtiuk KA, Gersh BJ, Washam JB, Granger CB. When cardiovascular medicines should be discontinued. Eur Heart J 2024; 45:2039-2051. [PMID: 38838241 DOI: 10.1093/eurheartj/ehae302] [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: 12/28/2023] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024] Open
Abstract
An integral component of the practice of medicine is focused on the initiation of medications, based on clinical practice guidelines and underlying trial evidence, which usually test the addition of novel medications intended for life-long use in short-term clinical trials. Much less attention is given to the question of medication discontinuation, especially after a lengthy period of treatment, during which patients age gets older and diseases may either progress or new diseases may emerge. Given the paucity of data, clinical practice guidelines offer little to no guidance on when and how to deprescribe cardiovascular medications. Such decisions are often left to the discretion of clinicians, who, together with their patients, express concern of potential adverse effects of medication discontinuation. Even in the absence of adverse effects, the continuation of medications without any proven effect may cause harm due to drug-drug interactions, the emergence of polypharmacy, and additional preventable spending to already strained health systems. Herein, several cardiovascular medications or medication classes are discussed that in the opinion of this author group should generally be discontinued, either for the prevention of potential harm, for a lack of benefit, or for the availability of better alternatives.
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Affiliation(s)
- Konstantin A Krychtiuk
- Duke Clinical Research Institute, 300 W Morgan Street, Durham, NC 27701, USA
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jeffrey B Washam
- Division of Clinical Pharmacology, Department of Medicine, Duke University, Durham, NC, USA
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Stuijt PJC, Heringa M, van Dijk L, Faber A, Burgers JS, Feenstra TL, Taxis K, Denig P. Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation. BMC PRIMARY CARE 2024; 25:210. [PMID: 38862899 PMCID: PMC11165805 DOI: 10.1186/s12875-024-02465-7] [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: 04/23/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (identifier: NCT05507177).
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Affiliation(s)
- Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Adrianne Faber
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Jako S Burgers
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Dutch National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands.
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Silva Almodóvar A, Keller MS, Lee J, Mehta HB, Manja V, Nguyen TPP, Pavon JM, Terman SW, Hoyle D, Mixon AS, Linsky AM. Deprescribing medications among patients with multiple prescribers: A socioecological model. J Am Geriatr Soc 2024; 72:660-669. [PMID: 37943070 PMCID: PMC10947820 DOI: 10.1111/jgs.18667] [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: 07/25/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023]
Abstract
Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.
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Affiliation(s)
- Armando Silva Almodóvar
- Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jiha Lee
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Veena Manja
- Veterans Affairs Northern California Healthcare System, Mather, California, USA
- University of California Davis, Sacramento, California, USA
| | - Thanh Phuong Pham Nguyen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Samuel W Terman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Hoyle
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy M Linsky
- General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Brunner L, Mooser B, Spinewine A, Rodondi N, Aubert CE. Older Adult Perspectives on Statin Continuation and Discontinuation in Primary Cardiovascular Disease Prevention: A Mixed-Methods Study. Patient Prefer Adherence 2024; 18:15-27. [PMID: 38196947 PMCID: PMC10773265 DOI: 10.2147/ppa.s432448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/10/2023] [Indexed: 01/11/2024] Open
Abstract
Background and Purpose Evidence for statin use for primary cardiovascular disease prevention in older adults is limited. When evidence on risk-benefit profile of a medication is uncertain, using it or not becomes a preference-sensitive decision. We aimed to assess and explore patient perspectives on continuation and discontinuation of statins used for primary cardiovascular prevention in older adults. Patients and Methods We used a convergent mixed-methods design, conducting in parallel a survey among 47 patients and three focus groups (FGs) with 14 patients total. We recruited patients aged ≥65 years and taking a statin for primary cardiovascular prevention. The survey and FGs aimed to assess and explore patient experiences of statin use, and views on statin continuation and discontinuation, including patient decision-making. Quantitative and qualitative data were first analyzed separately - descriptive statistics for quantitative data and thematic analysis for qualitative data - and then integrated to create metainferences, using joint displays. Results Forty-one percent of patients (N=19) were reluctant to discontinue the statin, whereas 22% (N=10) were willing to try discontinuing it. A reason to continue the statin was its perceived necessity, while self-estimated low cardiovascular risk and wish to reduce medication burden were given as reasons to discontinue it. Lack of expertise assumed by the patients to decide about statin continuation or discontinuation, uncertainty about statin indication, and fear of having a cardiovascular event after discontinuation made many patients uncertain about deciding to continue or discontinue the statin. In this context, 70% (N=33) would rather have their physician choose for them, and 94% (N=44) would continue taking the statin for as long as their physician told them to do so. Conclusion This study highlights factors that influence patient willingness to continue or discontinue statins, patient uncertainty about statin continuation or discontinuation, and the important role physicians play in the decision-making process.
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Affiliation(s)
- Laureline Brunner
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Blandine Mooser
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Spinewine
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Department of Pharmacy, Centre Hospitalier Universitaire (CHU) UCL Namur, Yvoir, Belgium
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carole Elodie Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Weir KR, Shang J, Choi J, Rana R, Vordenberg SE. Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation. JAMA Netw Open 2023; 6:e2337281. [PMID: 37819657 PMCID: PMC10568363 DOI: 10.1001/jamanetworkopen.2023.37281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Little is known about why older adults decline deprescribing recommendations, primarily because interventional studies rarely capture the reasons. Objective To examine factors important to older adults who disagree with a deprescribing recommendation given by a primary care physician to a hypothetical patient experiencing polypharmacy. Design, Setting, and Participants This online, vignette-based survey study was conducted from December 1, 2020, to March 31, 2021, with participants 65 years or older in the United Kingdom, the US, Australia, and the Netherlands. The primary outcome of the main study was disagreement with a deprescribing recommendation. A content analysis was subsequently conducted of the free-text reasons provided by participants who strongly disagreed or disagreed with deprescribing. Data were analyzed from August 22, 2022, to February 12, 2023. Main Outcomes and Measures Attitudes, beliefs, fears, and recommended actions of older adults in response to deprescribing recommendations. Results Of the 899 participants included in the analysis, the mean (SD) age was 71.5 (4.9) years; 456 participants (50.7%) were men. Attitudes, beliefs, and fears reported by participants included doubts about deprescribing (361 [40.2%]), valuing medications (139 [15.5%]), and a preference to avoid change (132 [14.7%]). Valuing medications was reported more commonly among participants who strongly disagreed compared with those who disagreed with deprescribing (48 of 205 [23.4%] vs 91 of 694 [13.1%], respectively; P < .001) or had personal experience with the same medication class as the vignette compared with no experience (93 of 517 [18.0%] vs 46 of 318 [12.1%], respectively; P = .02). Participants shared that improved communication (225 [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication preferences (137 [15.2%]) may increase their agreement with deprescribing. Participants who disagreed compared with those who strongly disagreed were more interested in additional communication (196 [28.2%] vs 29 [14.2%], respectively; P < .001), alternative strategies (117 [16.9%] vs 21 [10.2%], respectively; P = .02), or consideration of medication preferences (122 [17.6%] vs 15 [7.3%], respectively; P < .001). Conclusions and Relevance In this survey study, older adults who disagreed with a deprescribing recommendation were more interested in additional communication, alternative strategies, or consideration of medication preferences compared with those who strongly disagreed. These findings suggest that identifying the degree of disagreement with deprescribing could be used to tailor patient-centered communication about deprescribing in older adults.
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Affiliation(s)
- Kristie Rebecca Weir
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jenny Shang
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Jae Choi
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Ruchi Rana
- currently a graduate student at University of Michigan College of Pharmacy, Ann Arbor
| | - Sarah E. Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [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: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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