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Tang JY, Teng PHJ, Chen CY, Tan KT, Ang W, Lau S, Ang AGC, Kyaw KK, Tay XY, Lim WMS, Espeleta WDV, Lin H, Ding YY, Lun P. Appropriate Prescribing for older adults with Multimorbidity (Pro-M): protocol for a feasibility study. Arch Public Health 2024; 82:37. [PMID: 38500190 PMCID: PMC10949664 DOI: 10.1186/s13690-024-01264-x] [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: 08/18/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Potentially inappropriate prescribing is common among older adults with multimorbidity due to various reasons, from concurrent application of multiple single-disease clinical guidelines to fragmentation of care. Interventions such as medication review have been implemented worldwide to reduce inappropriate prescribing for older adults. However, the implementability of such interventions are underexplored in the outpatient clinics in Singapore's public hospitals. Hence, the Pro-M study aims to assess the feasibility of implementing a physician-pharmacist collaborative care intervention in geriatric medicine outpatient clinics to facilitate appropriate prescribing for older adults in Singapore. METHODS This is a single-arm, non-randomised feasibility study using a pre-post evaluation design. This study consists of two parts: (1) implementation phase of the intervention (6 months) and an (2) evaluation phase (3 months). Eligible patients will be recruited from geriatric medicine outpatient clinics at two public hospitals in Singapore through convenience sampling. The main components of the Pro-M intervention are: (1) pharmacist-facilitated medication reviews with feedback on any medication issues and potential recommendations to physicians, and (2) physicians communicating changes to other relevant prescribers. The evaluation phase will involve surveying and interviewing physicians and pharmacists involved in the implementation of the intervention. A mixed-method approach will be employed for data collection and analysis. The quantitative and qualitative findings will be triangulated and reported using Proctor's implementation outcomes: appropriateness, penetration, acceptability, fidelity, feasibility, and sustainability. A basic cost analysis will be conducted alongside the study. DISCUSSION This is a phase 2 study to test the feasibility of implementing an intervention that was co-created with stakeholders during phase 1 development of an intervention to optimise prescribing for older adults with multimorbidity. The implementation will be assessed using Proctor's implementation outcomes to provide insights on the process and the feasibility of implementing medication reviews for older adults with multimorbidity as a routine practice in outpatient clinics. Data collected from this study will inform a subsequent scale-up study. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05756478. Registered on 06 March 2023.
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Affiliation(s)
- Jia Ying Tang
- Geriatric Education & Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore.
| | - Poh Hoon June Teng
- Geriatric Education & Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore
| | | | - Keng Teng Tan
- Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Sabrina Lau
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Kay Khine Kyaw
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Xin Yong Tay
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | | | | | - Huimin Lin
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Geriatric Education & Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Penny Lun
- Geriatric Education & Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore
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Yang C, Teh YE, Chua NGS, Lee KLS, Ng RQM. An overview of multimorbidity and polypharmacy in older people living with HIV. Geriatr Gerontol Int 2024; 24 Suppl 1:49-59. [PMID: 37940135 DOI: 10.1111/ggi.14717] [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: 09/06/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
The availability of effective antiretroviral therapy (ART) has revolutionized the care of people living with HIV (PLHIV). As a result, PLHIV now have a life expectancy comparable with that of the general population. PLHIV are increasingly confronted with age-related comorbidities and geriatric syndromes, including frailty and polypharmacy, which occur at a higher prevalence and set in at an earlier age compared with their uninfected counterparts. The underlying pathophysiology for multimorbidity and polypharmacy are multifactorial, multidimensional and complex. Therefore, regular review and optimization of risk factors to maintain physical function, social and psychological health is of utmost importance. With an ever-growing population of older PLHIV, there is a pressing need to provide holistic care to address these emerging issues. Accelerated aging observed in PLHIV suggests that early involvement of a multidisciplinary team, including geriatricians, and implementation of integrated models of care can potentially improve the care of older PLHIV, who are at increased risk of frailty and complex multimorbidity. This article reviews the current global situation, discusses the challenges involved and suggests approaches to deliver comprehensive care for older PLHIV. Geriatr Gerontol Int 2024; 24: 49-59.
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Affiliation(s)
- Chen Yang
- Department of Geriatric Medicine, Singapore General Hospital, Outram Road, Singapore
| | - Yii Ean Teh
- Department of Infectious Disease, Singapore General Hospital, Outram Road, Singapore
| | | | | | - Rachel Qiao Ming Ng
- Department of Geriatric Medicine, Singapore General Hospital, Outram Road, Singapore
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Teng PHJ, Lun P, Tang JY, Tan KT, Ang W, Ding YY. Using multiple approaches to develop a physician-pharmacist collaborative care intervention to facilitate appropriate prescribing for older adults with multimorbidity. Arch Gerontol Geriatr 2023; 115:105110. [PMID: 37418820 DOI: 10.1016/j.archger.2023.105110] [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: 11/28/2022] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND AND OBJECTIVES This article discusses the development process of an intervention to facilitate appropriate prescribing for older adults with multimorbidity at geriatric medicine outpatient clinics. Both effectiveness and implementability were key aims, which were achieved by a systematic combination of different approaches guided by published guidance. METHODS Various frameworks and tools were used to guide the intervention development. They include The Medical Research Council Framework for complex health interventions as the overarching framework, supplemented by the Framework of Actions for Intervention Development and a taxonomy of intervention development approaches. RESULTS A combination of theory and evidence-based-, implementation-based and partnership approaches were used to develop the intervention. The Behaviour Change Wheel and Theoretical Domains Framework were used for intervention design. Three scoping reviews and two modified Delphi studies were conducted to build an evidence base on prescribing-related barriers and existing interventions. The findings were synthesised, assessed for implementability, and culminated in a co-creation exercise with physicians and pharmacists. The final intervention aims to facilitate collaboration between physicians and pharmacists and to improve communication and documentation of prescribing decisions. CONCLUSIONS Multiple approaches may be required when developing interventions that are effective and implementable. The study team's experiences in using published guidance, integrating different approaches, and co-creating the intervention with healthcare professionals provide a useful case study with lessons and insights for developers of complex interventions. Furthermore, systematic reporting of such research-based efforts would contribute to advancement of intervention development in healthcare and reducing research waste.
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Affiliation(s)
| | - Penny Lun
- Geriatric Education & Research Institute, Singapore
| | | | | | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore
| | - Yew Yoong Ding
- Geriatric Education & Research Institute, Singapore; Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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Hanna V, Chahine B, Souheil FA. Attitudes of Lebanese community-dwelling older adults towards deprescribing using the rPATD tool. Arch Gerontol Geriatr 2023; 105:104840. [PMID: 36343438 DOI: 10.1016/j.archger.2022.104840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the attitude of community-dwelling Lebanese older adults towards deprescribing using the Revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire and to determine patient-related factors that impact their willingness for deprescribing. METHODS A cross-sectional face-to-face survey was conducted in Lebanon over the period extending between October 2021 and March 2022 using the validated Arabic version of the rPATD questionnaire. It included ambulatory older adults who were 65 years of age or older, presenting to the community pharmacy, taking at least one chronic medication, and having intact cognition. KEY FINDINGS Of the 400 patients approached 300 (87%) agreed to participate. The mean age of participants was 65 (range 65-85 years) and 148 (56.3%) were females. The mean number of medications taken per patient was 5.8 ± 2.67 (range 1-18) and polypharmacy was reported among 188 patients (71.8%). Nearly all of study subjects 233 (89.0%) were willing to discontinue one or more of their regular medications if their physician said it was possible. The multivariate logistic regression analysis showed that the appropriateness of medications factor (OR= 3.9, 95% CI 1.308, 12.16, p=0.015) and patients' concern about stopping the medications factor (OR=0.116, 95% CI 0.033, 0.40, p = 0.001) were significantly associated with patients' willingness to deprescribe. CONCLUSION A noteworthy percentage of the Lebanese older outpatients were willing to stop one or more of their regular medications if their doctor recommends so. Patients' belief in appropriateness of medications and concerns about stopping were noted to significantly influence their willingness to deprescribe in this sample population.
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Affiliation(s)
- Venise Hanna
- PharmD Program, School of Pharmacy, Lebanese International University, Beirut 1103, Lebanon
| | - Bahia Chahine
- PharmD Program, School of Pharmacy, Lebanese International University, Beirut 1103, Lebanon.
| | - Farah Al Souheil
- PharmD Program, School of Pharmacy, Lebanese International University, Beirut 1103, Lebanon
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Cardona M, Stehlik P, Fawzy P, Byambasuren O, Anderson J, Clark J, Sun S, Scott I. Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review. Expert Opin Drug Saf 2020; 20:81-91. [PMID: 33213216 DOI: 10.1080/14740338.2021.1853704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life. Areas covered: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events. Expert opinion: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.
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Affiliation(s)
- Magnolia Cardona
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia.,Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Paulina Stehlik
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia.,Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Peter Fawzy
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia
| | - Oyungerel Byambasuren
- Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Jarrah Anderson
- School of Pharmacy and Pharmacology, Griffith University , Gold Coast, QLD, Australia
| | - Justin Clark
- Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Shelley Sun
- Sydney Medical School, The University of New South Wales , Kensington, NSW, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Metro South, QLD Health , Brisbane, QLD, Australia
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Kua CH, Reeve E, Tan DSY, Koh T, Soong JL, Sim MJL, Zhang TY, Chen YR, Ratnasingam V, Mak VSL, Lee SWH. Patients’ and Caregivers’ Attitudes Toward Deprescribing in Singapore. J Gerontol A Biol Sci Med Sci 2020; 76:1053-1060. [DOI: 10.1093/gerona/glaa018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
Background
Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs.
Method
A cross-sectional survey of two groups of participants was conducted using the Revised Patients’ Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants’ characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed.
Results
A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively.
Conclusions
Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.
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Affiliation(s)
- Chong-Han Kua
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Emily Reeve
- Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Doreen S Y Tan
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Khoo Teck Puat Hospital, Singapore
| | - Tsingyi Koh
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- National University Hospital, Singapore
| | - Jie Lin Soong
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Singapore General Hospital, Singapore
| | - Marvin J L Sim
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- National Healthcare Group Pharmacy, Singapore
| | - Tracy Y Zhang
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Ang Mo Kio-Thye Hua Kwan Hospital, Singapore
| | - Yi Rong Chen
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Tan Tock Seng Hospital, Singapore
| | - Vanassa Ratnasingam
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Vivienne S L Mak
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- School of Pharmacy, Taylor’s University Lakeside Campus, Subang Jaya, Selangor, Malaysia
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