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Jazbar J, Locatelli I, Kos M. Sedative load and anticholinergic burden among older adults in Slovenia over a decade: Potential for optimization of pharmacotherapy. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2024; 74:329-341. [PMID: 38815203 DOI: 10.2478/acph-2024-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
This study investigates the 10-year trend in the sedative and anticholinergic burden among older adults in Slovenia, with the aim of identifying opportunities to optimize pharmacotherapy in this population. A retrospective drug utilization analysis was conducted based on a national anonymized database of dispensed prescriptions from 2009 to 2019. The study employed the sedative load model and the anticholinergic cognitive burden scale to assess the sedative and anti cholinergic burden, respectively. The findings indicate that in 2019, 45.6 % and 40.8 % of older adults (≥ 65 years) used sedative and anticholinergic medications, respectively. A high sedative load and a clinically significant anticholinergic burden were observed in a considerable proportion of older adults (13.2 % and 11.2 %, respectively, in 2019). The age-standardized prevalence of sedative load and anti-cholinergic burden significantly decreased over the 10-year study period by 5.6 % and 1.7 %, respectively (absolute difference), while the prevalence of clinically significant anticholinergic burden remained stable. Notably, the age groups 85-89 years and above 90 years had an increase in the proportion of individuals with a clinically significant anticholinergic burden over the years. These results emphasize the need for targeted interventions, particularly in the oldest age groups, to promote safe and effective medication use among older adults.
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Affiliation(s)
- Janja Jazbar
- 1University of Ljubljana, Faculty of Pharmacy 1000 Ljubljana, Slovenia
| | - Igor Locatelli
- 1University of Ljubljana, Faculty of Pharmacy 1000 Ljubljana, Slovenia
| | - Mitja Kos
- 1University of Ljubljana, Faculty of Pharmacy 1000 Ljubljana, Slovenia
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Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
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Ndai AM, Morris EJ, Winterstein AG, Vouri SM. Evaluating Provider and Pharmacy Discordance in Potential Calcium Channel Blocker-Loop Diuretic Prescribing Cascade. Drugs Aging 2024; 41:177-186. [PMID: 38252391 DOI: 10.1007/s40266-023-01091-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prescribing cascades occur when a drug-induced adverse event is treated with a new medication. Identifying clinical scenarios in which prescribing cascades are more likely to occur may help determine ways to prevent prescribing cascades. OBJECTIVE To understand the extent to which discordant providers and discordant pharmacies contribute to the dihydropyridine calcium channel blocker (DH CCB)-loop diuretic prescribing cascade. STUDY POPULATION AND DESIGN A retrospective cohort study using Medicare Fee-For-Service data (2011-2018) of adults aged ≥ 66 years. EXPOSURES Patients who initiated DH CCB with subsequent initiation of loop diuretic (DH CCB-loop diuretic dyad) within 90 days or patients who initiated angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) with subsequent initiation of a loop diuretic (ACEI/ARB-loop diuretic dyad; control). MAIN OUTCOMES The primary outcomes were provider and pharmacy discordance for prescribing cascades and control drug pairs. Baseline clinical and socio-demographic characteristics were balanced using inverse probability of treatment weighting with propensity scores. RESULTS Overall, we identified 1987 DH CCB-loop diuretic dyads and 3148 ACEI/ARB-loop diuretic dyads. Discordant providers occurred in 64% of DH CCB-loop diuretic dyads and 55% of ACEI/ARB-loop diuretic dyads, while discordant pharmacies occurred in 19% of DH CCB-loop diuretic dyads and 16% of ACEI/ARB-loop diuretic dyads. After adjustment, the risk of having discordant providers was 20% {Relative Risk (RR) 1.20 [95% confidence interval (CI), 1.14-1.26]} higher in the DH CCB-loop diuretic dyad compared with the ACEI/ARB-loop diuretic dyad. Moreover, pharmacy discordance was 17% (RR 1.17 [95% CI 1.02-1.33]) higher. CONCLUSION Our findings suggest that discordant providers and discordant pharmacies were more commonly involved in the potential prescribing cascade when compared with a similar control dyad of medications. Opportunities for enhanced care coordination and medication reconciliation should be explored to prevent unnecessary polypharmacy.
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Affiliation(s)
- Asinamai M Ndai
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, PO Box 100496, Gainesville, FL, 32610, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
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Wehran T, Eidam A, Czock D, Kopitz J, Plaschke K, Mattern M, Haefeli WE, Bauer JM, Seidling HM. Development and Pilot Testing of an Algorithm-Based Approach to Anticholinergic Deprescribing in Older Patients. Drugs Aging 2024; 41:153-164. [PMID: 38319492 PMCID: PMC10869417 DOI: 10.1007/s40266-023-01089-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adverse anticholinergic drug reactions are common, yet evidence on how to reduce exposure to anticholinergic activity and reliably measure successful deprescribing is still scant. This study proposes an algorithm-based approach to evaluate and reduce anticholinergic load, and reports the results of its pilot testing. METHODS Based on published evidence and expert opinion, a list of 85 anticholinergic drugs and 21 algorithms for reducing anticholinergic load, e.g., by recommending alternative drugs with lower risk, were developed. An accompanying test battery was assembled by focusing on instruments that sensitively reflect anticholinergic load and may be sensitive to depict changes (Neuropsychological Assessment Battery to measure memory and attention, validated assessments for constipation, urinary symptoms, and xerostomia, as well as blood biomarkers). The approach was pilot-tested in a geriatric rehabilitation unit, with clinician feedback as the primary outcome and characterization of anticholinergic symptoms as the secondary outcome. The intervention was delivered by a pharmacist and a clinical pharmacologist who used the algorithms to generate personalized recommendation letters. RESULTS We included a total of 20 patients, 13 with anticholinergic drugs and 7 without. Recommendations were made for 22 drugs in nine patients from the intervention group, of which seven letters (78%) were considered helpful and 8/22 (36%) anticholinergic drugs were discontinued, reducing anticholinergic load in seven patients. In contrast to patients without drug change, memory assessment in patients with reduced anticholinergic load improved significantly after 2 weeks (6 ± 3 vs. -1 ± 6 points). CONCLUSIONS The approach was well received by the participating physicians and might support standardized anticholinergic deprescribing.
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Affiliation(s)
- Tanja Wehran
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Medical Faculty Heidelberg / Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Center for Geriatric Medicine, Heidelberg University Hospital, Agaplesion Bethanien Hospital, Rohrbacher Straße 149, 69126, Heidelberg, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, Agaplesion Bethanien Hospital, Rohrbacher Straße 149, 69126, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Medical Faculty Heidelberg / Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Kopitz
- Institute of Pathology, Heidelberg University, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Konstanze Plaschke
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Margarete Mattern
- Department of General Psychiatry, Heidelberg University Hospital, Voßstraße 4, 69115, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Medical Faculty Heidelberg / Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Martin Bauer
- Center for Geriatric Medicine, Heidelberg University Hospital, Agaplesion Bethanien Hospital, Rohrbacher Straße 149, 69126, Heidelberg, Germany
- Network Aging Research, Heidelberg University, Bergheimer Straße 20, 69115, Heidelberg, Germany
| | - Hanna Marita Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Medical Faculty Heidelberg / Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Kelley CJ, Niznik JD, Ferreri SP, Schlusser C, Armistead LT, Hughes TD, Henage CB, Busby-Whitehead J, Roberts E. Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing. Drugs Aging 2023; 40:1113-1122. [PMID: 37792262 PMCID: PMC10768261 DOI: 10.1007/s40266-023-01071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.
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Affiliation(s)
- Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tamera D Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Ellen Roberts
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
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Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open 2023; 6:e2336728. [PMID: 37787993 PMCID: PMC10548310 DOI: 10.1001/jamanetworkopen.2023.36728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. Objective To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. Design, Setting, and Participants A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. Main Outcomes and Measures The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. Results A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Conclusions and Relevance Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.
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Affiliation(s)
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Nicole Williams
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia
| | - Matthew K. Wynia
- University of Colorado Center for Bioethics and Humanities, Anschutz Medical Campus, Aurora
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Policy and Management, Colorado School of Public Health, Aurora
| | - Ariel R. Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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El-Dahiyat F, Jairoun AA, Al-Hemyari SS, Shahwan M, Hassan N, Jairoun S, Jaber AAS. Are pharmacists' knowledge and practice the key to promoting deprescribing of potentially inappropriate medication: a missing link between treatment and outcomes. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7146786. [PMID: 37116892 DOI: 10.1093/ijpp/riad027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Deprescribing is a novel strategy whereby medical professionals aim to optimize a patient's prescription program by removing redundant medications. Few studies have looked at the viewpoints of community pharmacists and other healthcare professionals on deprescribing in daily practice. This study's objectives included evaluating community pharmacists' deprescribing knowledge, attitudes and practices, as well as identifying the obstacles to and enablers of deprescribing in daily practice. METHODS Five pharmacy students in the last year of their studies polled employees of neighbourhood pharmacies in Abu Dhabi, Dubai, and the Northern Emirates from April 2022 to July 2022. The study's questionnaire was divided into two sections: questions that inquired about the respondents' demographic data and questions that evaluated the respondents' understanding and usage of the deprescribing of potentially harmful medications for patients. The original Bloom's cutoff points were revised and modified to assess the general knowledge and deprescribing practices of United Arab Emirates (UAE) community pharmacists. Multivariate logistic regression identified the variables influencing respondents' deprescribing knowledge and practice. KEY FINDINGS The average age of the participants was 30.8 ± 6.4 SD. Of the total, 255 (37.7%) were male and 422 (62.3%) were female. Pharmacists from independent pharmacies constituted 52.9% of the study sample and 47.1% were from Chain pharmacies. Among the participants, 58.8% (n = 398) had 1-5 years of experience and 41.2% (n = 279) had more than 5 years. Nearly three-quarters of the pharmacists (72.1%, 488) graduated from local universities and 27.9% (n = 189) graduated from regional/international universities. The vast majority of the study sample (84.8%, 574) were bachelor's degree holders and 88.3% (n = 598) were pharmacists in charge. Of the total, 69.3% (n = 469) received deprescribing training to treat patients with multimorbid diseases. The knowledge and practice score was 71.3% with a 95% confidence interval [70.2%, 72.4%]. Of the total participants, 113 (16.7%) had poor knowledge and practice about deprescribing, 393 (58.1%) had moderate knowledge and practice and 171 (25.3%) had good knowledge and practice. CONCLUSION This study highlights the level of understanding of community pharmacists about deprescribing in the UAE. Although most of the respondents in this study received training on deprescribing, less than half of the community pharmacists were unaware of certain classes (long-acting sulfonylureas, anti-diabetic, antihyperlipidemic and psychotropic drugs) of drugs that are candidates for potential deprescribing. This finding indicates that their knowledge about deprescribing was insufficient. Several barriers community pharmacists face in deprescribing were also identified, with patients' resistance and insufficience being the most prevalent. Therefore, there is a need for improved deprescribing practices to ensure drug safety.
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Affiliation(s)
- Faris El-Dahiyat
- Clinical Pharmacy Program, College of Pharmacy, Al Ain University, Al Ain, UAE
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, UAE
| | - Ammar Abdulrahman Jairoun
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor, Malaysia
- Health and Safety Department, Dubai Municipality, Dubai, UAE
| | - Sabaa Saleh Al-Hemyari
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor, Malaysia
- Pharmacy Department, Emirates Health Services, Dubai, UAE
| | - Moyad Shahwan
- College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, UAE
| | - Nageeb Hassan
- College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, UAE
| | - Sumaya Jairoun
- Pharmacy Department, Valiant Hospital, Dubai, UAE
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, Al mizhar Dubai, UAE
| | - Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, Al mizhar Dubai, UAE
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Christopher CM, Loong MCW, Blebil AQ, Bhuvan KC, Alex D, Ibrahim MIM, Ismail N. Helping Older Adults With Their Medication Use Problems: A Qualitative Study on Perspectives and Challenges of Primary Health Care Providers. Arch Gerontol Geriatr 2023; 111:105007. [DOI: 10.1016/j.archger.2023.105007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
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9
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Masnoon N, Lo S, Hilmer S. A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records. Br J Clin Pharmacol 2023; 89:687-698. [PMID: 36038522 PMCID: PMC10953400 DOI: 10.1111/bcp.15517] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The drug burden index (DBI) measures a person's total exposure to anticholinergic and sedative medications, which are commonly associated with harm. Through incorporating the DBI in electronic medical records (eMR) and implementing a DBI stewardship program, we aimed to determine (i) uptake of the steward's recommendations to deprescribe anticholinergic and/or sedative drugs by the medical team and (ii) whether accepted recommendations were actioned in hospital or recommended for follow-up by the General Practitioner post-discharge. METHODS A single-arm, non-randomised feasibility study was performed at an Australian tertiary referral metropolitan hospital. The stewardship pharmacist reviewed eMRs of patients aged ≥75 years with DBI scores > 0, during admission. The steward identified and discussed potential opportunities to deprescribe anticholinergic and/or sedative medications with the medical registrars. RESULTS Amongst 256 patients reviewed, the steward made 170 recommendations for 117 patients. Registrars agreed with 141 recommendations (82.9%) for 95 patients (81.2%), and actioned 115 deprescribing recommendations for 80 patients, most commonly for antidepressants and opioids. The 115 actioned recommendations resulted in 125 changes, with 44 changes to the inpatient drug chart and 81 additional changes recommended post-discharge in the discharge summary. CONCLUSION Opportunities exist for deprescribing anticholinergic and sedative medications in older inpatients and a DBI stewardship program may help implement these. It is important to capture different outcomes of deprescribing interventions, including in-hospital medication changes, recommendations in the Discharge Summary, sustainability of deprescribing and clinical outcomes.
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Affiliation(s)
- Nashwa Masnoon
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarita Lo
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
- Departments of Clinical Pharmacology and Aged CareRoyal North Shore HospitalSydneyNSWAustralia
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Bartlett A, Pace J, Arora A, Penm J. Self-Reflection and Peer-Assessments Effect on Pharmacy Students' Performance at Simulated Counselling Sessions. PHARMACY 2022; 11:pharmacy11010005. [PMID: 36649015 PMCID: PMC9844287 DOI: 10.3390/pharmacy11010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Verbal communication is a vital skill for pharmacists and essential for improving patient care. The aim of this study was to explore students' perception of the impact of self-reflection and self- and peer-assessment on simulated patient counselling sessions. METHODS Focus groups explored student perceptions of how this course and way of learning has impacted their performance at counselling patients. Data were analysed using iterative inductive thematic analysis procedures and mapped to the self-determination theory. RESULTS Nine focus groups with 47 pharmacy students. We identified three main themes and ten associated subthemes. These were learning style (sub-themes gradual introduction to assessment, learning through self-reflection videos, authentic assessment, individual learning compared to group learning, and learning through observation of best practice), feedback (sub-themes inconsistent feedback, summative feedback, perception of self and relationship with peers informing peer assessment) and benefits in real life practice. These themes mapped well to self-determination theory and highlighted that additional focus may be required for benefits in real-life practice. CONCLUSION Students' perceptions of self-reflection and self- and peer-assessment centred on learning style, feedback, and benefits in real-life practice. Additional focus on benefits of this unit of study in real-life practice and work integrated learning on placements may further strengthen the impact of these learning activities.
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Affiliation(s)
- Andrew Bartlett
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
- Correspondence: ; Tel.: +61-2-93518582
| | - Jessica Pace
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Angela Arora
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
- Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW 2031, Australia
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11
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Hu J, McMillan SS, Theodoros T, Collins JC, El-Den S, O’Reilly CL, Wheeler AJ. Psychotropic medication use in people living with severe and persistent mental illness in the Australian community: a cross-sectional study. BMC Psychiatry 2022; 22:705. [PMID: 36380352 PMCID: PMC9667665 DOI: 10.1186/s12888-022-04324-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Psychotropic polypharmacy and high-dose prescribing may play a role in therapy, however, with associated risks. The aim of this study was to describe current prescribing practices and use of four psychotropic medication groups (antipsychotics, antidepressants, mood stabilisers and benzodiazepines), focusing on polypharmacy (across and within groups) and high-dose prescribing in adults experiencing severe and persistent mental illness (SPMI) in the Australian community. METHODS 318 people taking psychotropic medication for SPMI had a medication review undertaken by a community pharmacist. Participants were recruited as part of an RCT from three Australian states/territories between September 2020-July 2021. All psychotropic medication and daily doses were recorded and reviewed for alignment with current clinical guidelines. Univariate and multiple logistic regression models investigated factors associated with antipsychotic, antidepressant, and mood stabiliser polypharmacy, and antipsychotic and antidepressant high-dose therapy. Variables included age, gender, geographic location, self- reported mental illness(es), hospital admission(s) in previous 6-months and prescriber type. RESULTS 806 psychotropic medications were prescribed for the 318 participants. Mood stabiliser polypharmacy was recorded in 19.0% of participants prescribed mood stabilisers; antipsychotic polypharmacy in 18.4% of participants prescribed antipsychotics; antidepressant polypharmacy in 11.3% of those prescribed antidepressants; and three participants (5.1%) were prescribed two benzodiazepines concurrently. Almost 18.6% of the cohort was receiving high-dose treatment; 18 participants were prescribed high-dose antipsychotics and 39 high-dose antidepressants, with two participants prescribed both. Adjusted logistic regression for polypharmacy found male gender, psychiatrist as sole prescriber, or multiple prescribers, were associated with antipsychotic polypharmacy. The adjusted model for high-dose therapy found psychiatrist as sole prescriber was significantly associated with antipsychotic and antidepressant high-dose prescribing. CONCLUSION Psychotropic polypharmacy was common in this community cohort experiencing SPMI. Whilst polypharmacy is not always inappropriate, it is a complex construct with potential benefits alongside potential risks. Benefits and harms need to be balanced however this practice is not supported by clear guidance to assist health practitioners. This study highlights the important need for regular medication reviews and strengthened communication between consumers and all healthcare professionals involved in community mental health care, to support safe and effective use of psychotropic medications.
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Affiliation(s)
- Jie Hu
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Sara S McMillan
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432School of Pharmacy and Medical Sciences, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432Centre for Mental Health, Griffith University, Nathan campus, 4111 Brisbane, Australia
| | - Theo Theodoros
- grid.1003.20000 0000 9320 7537University of Queensland Faculty of Medicine, Brisbane, Australia ,Metro South Mental Health Services, Brisbane, Australia
| | - Jack C Collins
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Sarira El-Den
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Claire L O’Reilly
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia. .,Centre for Mental Health, Griffith University, Nathan campus, 4111, Brisbane, Australia. .,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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12
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Goyal P, Safford M, Hilmer SN, Steinman MA, Matlock D, Maurer MS, Lachs M, Kronish IM. N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study. Br J Clin Pharmacol 2022; 88:4460-4473. [PMID: 35705532 PMCID: PMC9464693 DOI: 10.1111/bcp.15442] [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: 01/28/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medicine (New York, NY)
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Sarah N. Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital (Sydney, Australia)
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco (San Francisco, CA)
| | - Daniel Matlock
- Division of Geriatrics, University of Colorado (Denver, CO)
| | - Mathew S. Maurer
- Department of Medicine, Columbia University Irving Medical Center (New York, NY)
| | - Mark Lachs
- Division of Geriatrics, Weill Cornell Medicine (New York, NY)
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University, (New York, NY)
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13
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Niznik JD, Ferreri SP, Armistead LT, Kelley CJ, Schlusser C, Hughes T, Henage CB, Busby-Whitehead J, Roberts E. Primary-Care Prescribers' Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults. Drugs Aging 2022; 39:739-748. [PMID: 35896779 PMCID: PMC9330848 DOI: 10.1007/s40266-022-00967-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/23/2022]
Abstract
Purpose Opioids and benzodiazepines (BZDs) are frequently implicated as contributing to falls in older adults. Deprescribing of these medications continues to be challenging. This study evaluated primary-care prescribers’ confidence in and perceptions of deprescribing opioids and BZDs for older adults. Methods For this study, we conducted a quantitative analysis of survey data combined with an analysis of qualitative data from a focus group. A survey evaluating prescriber confidence in deprescribing opioids and BZDs was distributed to providers at 15 primary-care clinics in North Carolina between March-December 2020. Average confidence (scale 0–100) for deprescribing opioids, deprescribing BZDs, and deprescribing under impeding circumstances were reported. A virtual focus group was conducted in March 2020 to identify specific barriers and facilitators to deprescribing opioids and BZDs. Audio recordings and transcripts were analyzed using inductive coding. Results We evaluated 61 survey responses (69.3% response rate). Respondents were predominantly physicians (54.8%), but also included nurse practitioners (24.6%) and physician assistants (19.4%). Average overall confidence in deprescribing was comparable for opioids (64.5) and BZDs (65.9), but was lower for deprescribing under impeding circumstances (53.7). In the focus group, prescribers noted they met more resistance when deprescribing BZDs and that issues such as lack of time, availability of mental health resources, and patients seeing multiple prescribers were barriers to deprescribing. Conclusion Findings from quantitative and qualitative analyses identified that prescribers were moderately confident in their ability to deprescribe both opioids and BZDs in older adults, but less confident under potentially impeding circumstances. Future studies are needed to evaluate policies and interventions to overcome barriers to deprescribing opioids and BZDs in primary care. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-022-00967-6.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA. .,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA. .,Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Casey J Kelley
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Tamera Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellen Roberts
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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14
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Development and Validation of Comprehensive Healthcare Providers' Opinions, Preferences, and Attitudes towards Deprescribing (CHOPPED Questionnaire). PHARMACY 2022; 10:pharmacy10040076. [PMID: 35893715 PMCID: PMC9326567 DOI: 10.3390/pharmacy10040076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
Successful implementation of deprescribing requires exploring healthcare professionals’ opinions, preferences, and attitudes towards deprescribing. The aim of this study was to develop and validate the questionnaire exploring healthcare providers’ opinions preferences and attitudes towards deprescribing (CHOPPED questionnaire). This was a cross-sectional on-line survey. A comprehensive 58-item questionnaire, in two versions (for pharmacists and physicians), was developed through an extensive literature review and interviews with experts. The questionnaire was validated, and its reliability was assessed through data collected from 356 pharmacists and 109 physicians. Exploratory factor analysis was performed, and 37- and 35-item questionnaires were developed. Ten factors were identified: knowledge, awareness, patient barriers and facilitators, competencies barriers and facilitators, collaboration barriers and facilitators, and healthcare system barriers and facilitators. The CHOPPED tool has satisfactory face, content (CVR > 0.62) (content validity ratio), construct, and criterion validity. The reliability statistics of all factors in both versions was acceptable with Cronbach’s alpha > 0.6. Test−retest reliability analysis showed that gamma rank correlations of total factor scores were strong and very strong (between 0.519 and 0.938). The CHOPPED tool can be used as a valid and reliable tool to explore healthcare providers’ opinions and attitudes toward discontinuing medications in the primary care setting in Croatia.
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15
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Niznik JD, Collins BJ, Armistead LT, Larson CK, Kelley CJ, Hughes TD, Sanders KA, Carlson R, Ferreri SP. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review. Res Social Adm Pharm 2022; 18:2913-2921. [PMID: 34281786 PMCID: PMC8836277 DOI: 10.1016/j.sapharm.2021.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Affiliation(s)
- Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA; VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Brendan J Collins
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Claire K Larson
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Casey J Kelley
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Tamera D Hughes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kimberly A Sanders
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina, Health Sciences Library, Chapel Hill, NC, USA
| | - Stefanie P Ferreri
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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16
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Kalim RA, Cunningham CJ, Ryder SA, McMahon NM. Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF). Drugs Aging 2022; 39:935-947. [PMID: 36409404 PMCID: PMC9676799 DOI: 10.1007/s40266-022-00985-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting. METHOD Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software. RESULTS A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome. CONCLUSION Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.
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Affiliation(s)
- Reham A Kalim
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Conal J Cunningham
- St James's Hospital, James's Street, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Sheila A Ryder
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Niamh M McMahon
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- St James's Hospital, James's Street, Dublin, Ireland
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17
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Cunningham Y, Wood K, Stewart C, Nakham A, Newlands R, Gallacher KI, Quinn TJ, Ellis G, Lowrie R, Myint PK, Bond C, Mair FS. Understanding Stakeholder Views Regarding the Design of an Intervention Trial to Reduce Anticholinergic Burden: A Qualitative Study. Front Pharmacol 2021; 12:608208. [PMID: 34867311 PMCID: PMC8633300 DOI: 10.3389/fphar.2021.608208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anticholinergic burden (ACB), is defined as the cumulative effect of anticholinergic medication which are widely prescribed to older adults despite increasing ACB being associated with adverse effects such as: falls, dementia and increased mortality. This research explores the views of health care professionals (HCPs) and patients on a planned trial to reduce ACB by stopping or switching anticholinergic medications. The objectives were to explore the views of key stakeholders (patients, the public, and HCPs) regarding the potential acceptability, design and conduct of an ACB reduction trial. Materials and Methods: We conducted qualitative interviews and focus groups with 25 HCPs involved in prescribing medication with anticholinergic properties and with 22 members of the public and patients who were prescribed with the medication. Topic guides for the interviews and focus groups explored aspects of feasibility including: 1) views of a trial of de-prescribing/medication switching; 2) how to best communicate information about such a trial; 3) views on who would be best placed and preferred to undertake such medication changes, e.g., pharmacists or General Practitioners (GPs)? 4) perceived barriers and facilitators to trial participation and the smooth conduct of such a trial; 5) HCP views on the future implementability of this approach to reducing ACB and 6) patients' willingness to be contacted for participation in a future trial. Qualitative data analysis was underpinned by Normalization Process Theory. Results: The public, patients and HCPs were supportive of an ACB reduction trial. There was consensus among the different groups that key points to consider with such a trial included: 1) ensuring patient engagement throughout to enable concerns/potential pitfalls to be addressed from the beginning; 2) ensuring clear communication to minimise potential misconceptions about the reasons for ACB reduction; and 3) provision of access to a point of contact for patients throughout the life of a trial to address concerns; The HCPs in particular suggested two more key points: 4) minimise the workload implications of any trial; and 5) pharmacists may be best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with GPs. Conclusion: Patients, the public and HCPs are supportive of trials to reduce ACB. Good communication and patient engagement during design and delivery of a trial are essential as well as safety netting and minimising workload.
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Affiliation(s)
- Yvonne Cunningham
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Karen Wood
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Carrie Stewart
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Athagran Nakham
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Rumana Newlands
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Katie I Gallacher
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Terence J Quinn
- Academic Geriatric Medicine, New Lister Building, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | - Richard Lowrie
- Pharmacy Services, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Phyo Kyaw Myint
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Christine Bond
- The School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Frances S Mair
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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18
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Kouladjian O'Donnell L, Reeve E, Hilmer SN. Development, validation and evaluation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)©. Res Social Adm Pharm 2021; 18:3174-3183. [PMID: 34583897 DOI: 10.1016/j.sapharm.2021.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/12/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES 1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia; 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia. METHODS This study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building; b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia; and c) the evaluation phase, using mixed-methods analyses. RESULTS The exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability. DISCUSSION AND CONCLUSIONS Involving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software.
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Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| | - Emily Reeve
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia; Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Science, University of South Australia, Adelaide, South Australia, Australia.
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia.
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19
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Tegegn HG, Gebresillassseie BM, Erku DA, Elias A, Yabeyu AB, Ayele AA. Deprescribing practice in a resource-limited setting: Healthcare providers' insights. Int J Clin Pract 2021; 75:e14356. [PMID: 33974310 DOI: 10.1111/ijcp.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 05/07/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Inappropriate polypharmacy poses risks of adverse drug events, high healthcare costs and mortality. Deprescribing could minimise inappropriate polypharmacy and the consequences thereof. The aim of this study was to evaluate healthcare providers' (HCPs') attitudes toward and experiences with deprescribing practice in Ethiopia. METHODS We conducted an institution-based cross-sectional survey among HCPs at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. We used a validated questionnaire developed by Linsky et al. The tool included questions that explore medication characteristics, current patient clinical factors, predictions of future health states, patients' resources to manage their own health and education and experience. One-way ANOVA was used to test the association between sociodemographic variables and their perception of deprescribing decisions. RESULTS Of 85 HCPs approached, about 82 HCPs completed the survey, giving a response rate of 96.5%. Most of the participants (n = 73, 89%) have scored less than 1.5 points showing they are reluctant to proactively deprescribe. Physicians seem to be affected by the significant physical health conditions (mean = 1.68) and clinical endpoint like blood pressure (mean = 1.5) to make deprescribing decisions. According to the post hoc analysis of one-way ANOVA, clinical pharmacists seemed to have a better attitude toward deprescribing decisions compared with physicians (P = .025). CONCLUSION HCPs' decision to discontinue a medication could be multifactorial. Physicians could be influenced by physical health condition and clinical endpoints for deprescribing decision. Future studies should emphasise on barriers and facilitators to deprescribing practice specific to the context in Ethiopia.
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Affiliation(s)
- Henok Getachew Tegegn
- School of Rural Medicine, Pharmacy, University of New England, Armidale, NSW, Australia
- College of Medicine and Health Science, Clinical Pharmacy Department, University of Gondar, Gondar, Ethiopia
| | | | - Daniel Asfaw Erku
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Asrat Elias
- College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Abdella Birhan Yabeyu
- Collage of Health Science, Department of Pharmacology and Clinical Pharmacy, Addis Ababa University (AAU), Addis Ababa, Ethiopia
| | - Asnakew Achaw Ayele
- College of Medicine and Health Science, Clinical Pharmacy Department, University of Gondar, Gondar, Ethiopia
- School of Health, University of New England, Armidale, NSW, Australia
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20
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Magin P, Quain D, Tapley A, van Driel M, Davey A, Holliday E, Ball J, Kaniah A, Turner R, Spike N, FitzGerald K, Hilmer S. Deprescribing in older patients by early-career general practitioners: Prevalence and associations. Int J Clin Pract 2021; 75:e14325. [PMID: 33960089 DOI: 10.1111/ijcp.14325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 12/09/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
RATIONALE AND AIMS Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs. METHODS A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines. RESULTS One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration). CONCLUSION These findings will have important implications for the education of GPs in deprescribing as a clinical skill.
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Affiliation(s)
- Parker Magin
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Debbie Quain
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Amanda Tapley
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Mieke van Driel
- Discipline of General Practice and Primary Care Clinical Unit, Faculty of Medicine, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Andrew Davey
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Jean Ball
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ashwin Kaniah
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Rachel Turner
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Medical Education, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT) Churchill, Churchill, Vic, Australia
- Department of General Practice and Primary Health Care Carlton, University of Melbourne, Melbourne, Vic, Australia
| | | | - Sarah Hilmer
- University of Sydney and Royal North Shore Hospital, Kolling Institute, St Leonards, NSW, Australia
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21
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Stewart C, Gallacher K, Nakham A, Cruickshank M, Newlands R, Bond C, Myint PK, Bhattacharya D, Mair FS. Barriers and facilitators to reducing anticholinergic burden: a qualitative systematic review. Int J Clin Pharm 2021; 43:1451-1460. [PMID: 34173123 PMCID: PMC8642323 DOI: 10.1007/s11096-021-01293-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/29/2021] [Indexed: 02/07/2023]
Abstract
Background Despite common use, anticholinergic medications have been associated with serious health risks. Interventions to reduce their use are being developed and there is a need to understand their implementation into clinical care. Aim of review This systematic review aims to identify and analyse qualitative research studies exploring the barriers and facilitators to reducing anticholinergic burden. Methods Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms. Peer reviewed studies published in English presenting qualitative research in relation to the barriers and facilitators of deprescribing anticholinergic medications, involving patients, carers or health professionals were eligible. Normalization Process Theory was used to explore and explain the data. Results Of 1764 identified studies, two were eligible and both involved healthcare professionals (23 general practitioners, 13 specialist clinicians and 12 pharmacists). No studies were identified that involved patients or carers. Barriers to collaborative working often resulted in poor motivation to reduce anticholinergic use. Low confidence, system resources and organisation of care also hindered anticholinergic burden reduction. Good communication and relationships with patients, carers and other healthcare professionals were reported as important for successful anticholinergic burden reduction. Having a named person for prescribing decisions, and clear role boundaries, were also important facilitators. Conclusions This review identified important barriers and facilitators to anticholinergic burden reduction from healthcare provider perspectives which can inform implementation of such deprescribing interventions. Studies exploring patient and carer perspectives are presently absent but are required to ensure person-centeredness and feasibility of future interventions.
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Affiliation(s)
- Carrie Stewart
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, 1:128, Polwarth Building, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK.
| | - Katie Gallacher
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Athagran Nakham
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, 1:128, Polwarth Building, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK
| | - Moira Cruickshank
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Rumana Newlands
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Christine Bond
- Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, 1:128, Polwarth Building, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK
| | | | - Frances S Mair
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
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22
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Baysari MT, Duong MH, Hooper P, Stockey-Bridge M, Awad S, Zheng WY, Hilmer SN. Supporting deprescribing in hospitalised patients: formative usability testing of a computerised decision support tool. BMC Med Inform Decis Mak 2021; 21:116. [PMID: 33820536 PMCID: PMC8022373 DOI: 10.1186/s12911-021-01484-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/25/2021] [Indexed: 11/12/2022] Open
Abstract
Background Despite growing evidence that deprescribing can improve clinical outcomes, quality of life and reduce the likelihood of adverse drug events, the practice is not widespread, particularly in hospital settings. Clinical risk assessment tools, like the Drug Burden Index (DBI), can help prioritise patients for medication review and prioritise medications to deprescribe, but are not integrated within routine care. The aim of this study was to conduct formative usability testing of a computerised decision support (CDS) tool, based on DBI, to identify modifications required to the tool prior to trialling in practice. Methods Our CDS tool comprised a DBI MPage in the electronic medical record (clinical workspace) that facilitated review of a patient’s DBI and medication list, access to deprescribing resources, and the ability to deprescribe. Two rounds of scenario-based formative usability testing with think-aloud protocol were used. Seventeen end-users participated in the testing, including junior and senior doctors, and pharmacists. Results Participants expressed positive views about the DBI CDS tool but testing revealed a number of clear areas for improvement. These primarily related to terminology used (i.e. what is a DBI and how is it calculated?), and consistency of functionality and display. A key finding was that users wanted the CDS tool to look and function in a similar way to other decision support tools in the electronic medical record. Modifications were made to the CDS tool in response to user feedback. Conclusion Usability testing proved extremely useful for identifying components of our CDS tool that were confusing, difficult to locate or to understand. We recommend usability testing be adopted prior to implementation of any digital health intervention. We hope our revised CDS tool equips clinicians with the knowledge and confidence to consider discontinuation of inappropriate medications in routine care of hospitalised patients. In the next phase of our project, we plan to pilot test the tool in practice to evaluate its uptake and effectiveness in supporting deprescribing in routine hospital care. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01484-z.
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Affiliation(s)
- Melissa T Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, Charles Perkins Centre, D17, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Mai H Duong
- Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney and Royal North Shore Hospital, Sydney, Australia.,Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, Australia
| | | | | | - Selvana Awad
- Clinical Engagement and Patient Safety, eHealth NSW, Sydney, Australia
| | - Wu Yi Zheng
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, Charles Perkins Centre, D17, The University of Sydney, Sydney, NSW, 2006, Australia.,Black Dog Institute, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney and Royal North Shore Hospital, Sydney, Australia.,Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, Australia
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23
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Soong C, Burry L, Greco M, Tannenbaum C. Advise non-pharmacological therapy as first line treatment for chronic insomnia. BMJ 2021; 372:n680. [PMID: 33757960 DOI: 10.1136/bmj.n680] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Christine Soong
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health, Toronto, ON M5G 1X5, Canada
- Centre for Quality and Patient Safety, University of Toronto, ON, Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | | | - Cara Tannenbaum
- Faculté de Médicine, Institut Universitaire de Gériatrie de Montreal, Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
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24
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Moecker R, Terstegen T, Haefeli WE, Seidling HM. The influence of intervention complexity on barriers and facilitators in the implementation of professional pharmacy services - A systematic review. Res Social Adm Pharm 2021; 17:1651-1662. [PMID: 33579611 DOI: 10.1016/j.sapharm.2021.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 01/06/2021] [Accepted: 01/24/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Community pharmacies increasingly offer professional pharmacy services, whose implementation is often influenced by facilitating or obstructive implementation factors. The occurrence and composition of implementation factors vary among different services with discrete characteristics and complexity of the intervention, making it difficult to foresee potential barriers in implementation. OBJECTIVE(S) This paper investigates potential associations between intervention complexity and occurring implementation factors. METHODS A systematic literature search on the implementation factors and intervention complexity of professional pharmacy services in the community setting was carried out in electronic databases (PubMed, CINAHL, and PsycINFO) throughout December 2018. Implementation factors were extracted from semi-structured interviews, focus groups, and surveys with community pharmacists and categorized using the Consolidated Framework for Implementation Research (CFIR). The complexity of each service was assessed using the following complexity parameters: (I) number of involved healthcare professions, (II) number of service components such as recruiting of patients, screening intervention, and follow-up, (III) frequency of the service, (IV) expenditure of time per patient (encounter), and (V) workflow distortion, i.e. booking appointments for intervention with the patient. Finally, the association between implementation factors and intervention complexity was analyzed by quantifying implementation factors and by relating them to specific intervention characteristics using Fisher's exact test. RESULTS 15 studies covering a broad spectrum of professional pharmacy services were included. There was a trend that in services with higher complexity more implementation factors occurred (p = 0.094). Single key complexity parameters can trigger specific implementation factors. For instance, general practitioner and pharmacy technician involvement were significantly associated with interprofessional communication and leadership engagement, respectively. CONCLUSION Key implementation factors and associated complexity parameters seem to be of similar or more importance than the total number of implementation factors with regard to successful implementation. By assessing various complexity parameters of an intervention, potential key barriers could be identified and subsequently addressed prior to implementation.
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Affiliation(s)
- Robert Moecker
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Theresa Terstegen
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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25
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Stocksdale B, Nagpal S, Hixson JD, Johnson DR, Rai P, Shivaprasad A, Tremont-Lukats IW. Neuro-Oncology Practice Clinical Debate: long-term antiepileptic drug prophylaxis in patients with glioma. Neurooncol Pract 2020; 7:583-588. [PMID: 33312673 DOI: 10.1093/nop/npaa026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Patients with primary brain tumors often experience seizures, which can be the presenting symptom or occur for the first time at any point along the illness trajectory. In addition to causing morbidity, seizures negatively affect independence and quality of life in other ways, for example, by leading to loss of driving privileges. Long-term therapy with antiepileptic drugs (AEDs) is the standard of care in brain tumor patients with seizures, but the role of prophylactic AEDs in seizure-naive patients remains controversial. In this article, experts in the field discuss the issues of AED efficacy and toxicity, and explain their differing recommendations for routine use of prophylactic AEDs.
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Affiliation(s)
- Brian Stocksdale
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Seema Nagpal
- Department of Neurology, Stanford University, California
| | - John D Hixson
- Department of Neurology, University of California San Francisco
| | | | - Prashant Rai
- Department of Neurology, The University of Texas Medical Branch at Galveston
| | - Akhil Shivaprasad
- Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Texas
| | - Ivo W Tremont-Lukats
- Kenneth R. Peak Brain and Pituitary Tumor Center, Houston Methodist Hospital, Texas.,Department of Neurosurgery, Houston Methodist Hospital, Texas
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26
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Korenvain C, MacKeigan LD, Dainty KN, Guilcher SJ, McCarthy LM. Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel. Res Social Adm Pharm 2020; 16:1746-1753. [DOI: 10.1016/j.sapharm.2020.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 01/05/2023]
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Lonchampt S, Gerber F, Aubry JM, Desmeules J, Besson M, Kosel M. TOP-ID: a Delphi technique-guided development of a prescription and deprescription tool for adults with intellectual disabilities. BMJ Open 2020; 10:e039208. [PMID: 33148748 PMCID: PMC7643515 DOI: 10.1136/bmjopen-2020-039208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Adults with an intellectual disability (AWID) are often polymedicated because of somatic and psychiatric health problems. Besides, they may display challenging behaviours, leading to off-label prescription of psychotropic drugs, without efficacy and with numerous adverse effects. In this context, a prescription/deprescription tool (Tool for Optimising Prescription in Intellectual Disability/TOP-ID) was developed to improve the care of AWID. This paper describes how TOP-ID was designed. DESIGN Four-step consensus-based process involving a review of the literature, eight semistructured interviews and a two-round Delphi process. SETTING Seventeen general practices and university and general hospitals from Belgium, France and Switzerland. PARTICIPANTS Eighteen French-speaking physicians from different domains of expertise participated in the Delphi process. PRIMARY AND SECONDARY OUTCOME MEASURES For the Delphi iteration process, consensus was defined as at least a 65% agreement between the experts. RESULTS Two rounds were needed for the Delphi process. Eighty-one items of the tool were submitted to 18 out of 35 recruited French-speaking experts during the first round. Sixty-nine per cent of the items reached a rate of agreement of 65% or more in that round. Thirteen questions were reformulated and resubmitted for the second Delphi iteration round. All of the statements reached a rate of agreement of 65% or more in the second round. CONCLUSION TOP-ID is the first prescription-deprescription tool developed specifically for AWIDs in French. It is intended to help prescribers document patient care in order to reduce prescription errors and to improve safety. The next steps of the project include the development of an electronic version of TOP-ID and a utility study.
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Affiliation(s)
- Sophie Lonchampt
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- School of Pharmaceutical Sciences of Geneva and Lausanne, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Fabienne Gerber
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jean-Michel Aubry
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- School of Pharmaceutical Sciences of Geneva and Lausanne, Faculty of Science, University of Geneva, Geneva, Switzerland
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Marie Besson
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Multidisciplinary Pain Center, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive care and Pharmacology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Markus Kosel
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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Kouladjian O'Donnell L, Gnjidic D, Sawan M, Reeve E, Kelly PJ, Chen TF, Bell JS, Hilmer SN. Impact of the Goal-directed Medication Review Electronic Decision Support System on Drug Burden Index: A cluster-randomised clinical trial in primary care. Br J Clin Pharmacol 2020; 87:1499-1511. [PMID: 32960464 DOI: 10.1111/bcp.14557] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS The Goal-directed Medication Review Electronic Decision Support System (G-MEDSS) assesses and reports a patient's goals, attitudes to deprescribing and Drug Burden Index (DBI) score, a measure of cumulative exposure to anticholinergic and sedative medications. This study evaluated the effect of implementing G-MEDSS in home medicines reviews (HMRs) on DBI exposure and clinical outcomes. METHODS A cluster-randomised clinical trial was performed across Australia. Accredited clinical pharmacists were randomised into intervention (G-MEDSS with usual care HMR) or comparison groups (usual care HMR alone). Patients were recruited by pharmacists from those routinely referred by general practitioners for HMR. The primary outcome was the proportion of patients with any reduction in DBI at 3-months follow-up. Secondary outcomes included change in DBI continuous score at 3-months, HMR recommendations to change DBI and clinical outcomes. RESULTS There were 201 patient participants at baseline (n = 88 intervention, n = 113 comparison), with 159 followed-up at 3-months (n = 63 intervention, n = 96 comparison). The proportion of patients with a reduction in DBI was not significantly different at 3-months (intervention 17%, comparison 11%; adjusted odds ratio 1.44, 95% confidence interval 0.56-3.80). Regarding secondary outcomes, there was no difference in change in DBI score at 3-months. However, the HMR report made recommendations to reduce DBI for a significantly greater proportion of patients in the intervention than in the comparison group (intervention 37%, comparison 14%; adjusted odds ratio 3.20, 95% confidence interval 1.50-6.90). No changes were observed in clinical outcomes. CONCLUSION Implementation of G-MEDSS within HMR did not reduce patients' DBI at 3 months compared with usual care HMR.
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Affiliation(s)
- Lisa Kouladjian O'Donnell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Mouna Sawan
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Timothy F Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - J Simon Bell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sarah N Hilmer
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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29
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Farkas AH, Winn A, Pezzin LE, Fergestrom N, Laud P, Neuner JM. The Use and Concurrent Use of Side Effect Controlling Medications Among Women on Aromatase Inhibitors. J Womens Health (Larchmt) 2020; 30:131-136. [PMID: 33103945 DOI: 10.1089/jwh.2020.8493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Women on aromatase inhibitors (AIs) as part of their breast cancer treatment often experience difficult to control side effects. Although there are several medications to manage the side effects of AI therapy, many of them are associated with their own risk, particularly sedation. The objective of this study was to describe the prescribing practices for side effect managing (SE) medications among women with breast cancer on AI therapy and to assess for combinations of medications that may present a clinical risk to patients. Methods: Retrospective data analysis using Surveillance, Epidemiology and End Results (SEER)-Medicare data of all women aged 66-90 years with stage I-III hormone positive breast cancer diagnosed between 2008 and 2014 who initiated AI therapy within 12 months of their diagnosis. We determined the percentage of patients prescribed an SE medication in the 12 months prior and in the 24 months after the initiation of AI therapy. We calculated the number of prescriptions and the number of days of overlapping (i.e., >1 SE) prescriptions, and examined predictors of overlapping prescriptions. Results: The use of SE medications was pervasive and increased after initiation of AI therapy. The most commonly prescribed medications were opiates (55.1%), selective serotonin reuptake inhibitors (22.6%), benzodiazepines (18.4%), tramadol (17.7%) and gabapentin (14.6%). In total 15.5% of patients had overlapping prescriptions; among those, 36.2% had three overlapping prescriptions. Prior use was the strongest predictor of overlapping prescriptions with an odds ratio of 7.9 (95% confidence interval: 7.17-8.77). Conclusion: Among women on AI therapy, the use of SE medications is common and many have overlapping prescriptions raising concern for potential harm from polypharmacy.
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Affiliation(s)
- Amy H Farkas
- Division of General Internal Medicine Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Milwaukee VA Medicine Center, Milwaukee, Wisconsin, USA
| | - Aaron Winn
- Department of Clinical Sciences School of Pharmacy Medical College of Wisconsin, and Milwaukee, Wisconsin, USA.,Center for Advancing Population Science Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liliana E Pezzin
- Institue for Health and Society, Center for Healthcare Delivery Science Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Fergestrom
- Center for Advancing Population Science Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Prakash Laud
- Division of Biostatistics Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joan M Neuner
- Division of General Internal Medicine Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Bondurant-David K, Dang S, Levy S, Sperlea D, Vanier MC, Gerardi S, David PM. Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 28:635-642. [PMID: 33094884 DOI: 10.1111/ijpp.12674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Patients undergoing haemodialysis receive on average 10-17 medications, which increase the risk of falls, adverse drug reactions and hospitalizations. Supervised discontinuation of potentially inappropriate medications may lower these risks. Although many calls have been made for deprescribing in the haemodialysis setting, little is known about how patients and providers in this setting experience it. The aim of this study is to explore patient and provider experiences and perceptions of one of the rare deprescribing intervention in haemodialysis. METHODS Ten semi-structured interviews were held with patients, and a focus group was done with dialysis clinic team members at a Montreal area health network's haemodialysis clinic after the implementation of a standardized deprescribing intervention using the patient-as-partner approach. The interviews and focus group were recorded, and verbatims were coded to determine emerging themes. Grounded theory was used for interview guide design and data analysis. RESULTS The three emerging themes were (1) ambivalence towards medication creating a favourable context for deprescribing, (2) the empowering elements of the deprescribing process and (3) the uncertain future of deprescribing in the clinics even though the intervention was considered successful. CONCLUSION Haemodialysis patients and providers viewed deprescribing favourably, believed the intervention was valuable, and offered suggestions for long term implementation while expressing concerns about feasibility. Notwithstanding the underlying uncertainties, a structured and integrated approach in routine practice involving all members of the care team may facilitate the continuity of deprescribing as an intervention in the setting of a haemodialysis clinic.
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Affiliation(s)
- Kaitlin Bondurant-David
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
| | - Sébastien Dang
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
| | - Shirel Levy
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
| | - David Sperlea
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
| | - Marie-Claude Vanier
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
| | - Savannah Gerardi
- Département de Pharmacie, Hôpital de la Cité-de-la-Santé, CISSS de Laval, Laval, Canada
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Gerlach N, Michiels-Corsten M, Viniol A, Schleef T, Junius-Walker U, Krause O, Donner-Banzhoff N. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study. BMC FAMILY PRACTICE 2020; 21:183. [PMID: 32887551 PMCID: PMC7487755 DOI: 10.1186/s12875-020-01255-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022]
Abstract
Background Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs’, community pharmacists’ and specialist providers’ role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches. Method Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework. Results Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains ‘Social/professional role and identity’ (1), ‘Social influences’ (2), ‘Reinforcement’ (3) and ´Environmental context and resources’ (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients’ trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs’ role and deprescribing attempts. Reinforcements (3) negatively affected GPs’ and pharmacists’ effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized. Conclusion Understanding stakeholders’ role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.
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Affiliation(s)
- Navina Gerlach
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany.
| | - Matthias Michiels-Corsten
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
| | - Annika Viniol
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
| | - Tanja Schleef
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Ulrike Junius-Walker
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Olaf Krause
- Hannover Medical School, Institute of General Practice, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice, University of Marburg, Karl-von-Frisch-Straße 4, D-35043, Marburg, Germany
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Turner J, Kantilal K, Kantilal K, Holmes H, Koczwara B. Optimising Medications for Patients With Cancer and Multimorbidity: The Case for Deprescribing. Clin Oncol (R Coll Radiol) 2020; 32:609-617. [DOI: 10.1016/j.clon.2020.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/24/2020] [Accepted: 05/19/2020] [Indexed: 12/18/2022]
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Anticholinergic Burden in Children, Adults and Older Adults in Slovenia: A Nationwide Database Study. Sci Rep 2020; 10:9337. [PMID: 32518392 PMCID: PMC7283335 DOI: 10.1038/s41598-020-65989-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/17/2020] [Indexed: 11/11/2022] Open
Abstract
Anticholinergic burden has been widely studied in specific patient populations with specific conditions. However, the prevalence in the general population is poorly understood. This retrospective cross-sectional study was a nationwide database analysis of outpatient prescriptions of anticholinergic medications. The study was based on Slovenian health claims data of all outpatient prescriptions in 2018. Anticholinergic burden was evaluated using the Anticholinergic Cognitive Burden scale. Three age groups were analysed: children (≤18 years), adults (19–64 years) and older adults (≥65 years). Anticholinergic medications were prescribed to 29.8% of the participants; 7.6% were exposed to a clinically significant anticholinergic burden. The proportion of patients exposed to anticholinergic burden was highest in older adults (43.2%), followed by adults (25.8%) and children (20.7%). The most frequently prescribed medications with the highest anticholinergic activity were antipsychotics and medications for urinary diseases (42.8% and 40.2%, respectively). Medications with second highest activity were mostly antiepileptics (87.3%). Medications with possible anticholinergic activity included diverse therapeutic groups. Anticholinergic burden is highest in older adults but is also considerable among adults and children. Medications with anticholinergic activity belong to diverse therapeutic groups. Further research is needed on safe use of these medications in all age groups.
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Kennie-Kaulbach N, Cormier R, Kits O, Reeve E, Whelan AM, Martin-Misener R, Burge F, Burgess S, Isenor JE. Influencers on deprescribing practice of primary healthcare providers in Nova Scotia: An examination using behavior change frameworks. MEDICINE ACCESS @ POINT OF CARE 2020; 4:2399202620922507. [PMID: 36204093 PMCID: PMC9413600 DOI: 10.1177/2399202620922507] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/08/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Deprescribing is a complex process requiring consideration of behavior change theory to improve implementation and uptake. Aim: The aim of this study was to describe the knowledge, attitudes, beliefs, and behaviors that influence deprescribing for primary healthcare providers (family physicians, nurse practitioners (NPs), and pharmacists) within Nova Scotia using the Theoretical Domains Framework version 2 (TDF(v2)) and the Behavior Change Wheel. Methods: Interviews and focus groups were completed with primary care providers (physicians, NPs, and pharmacists) in Nova Scotia, Canada. Coding was completed using the TDF(v2) to identify the key influencers. Subdomain themes were also identified for the main TDF(v2) domains and results were then linked to the Behavior Change Wheel—Capability, Opportunity, and Motivation components. Results: Participants identified key influencers for deprescribing including areas related to Opportunity, within TDF(v2) domain Social Influences, such as patients and other healthcare providers, as well as Physical barriers (TDF(v2) domain Environmental Context and Resources), such as lack of time and reimbursement. Conclusion: Our results suggest that a systematic approach to deprescribing in primary care should be supported by opportunities for patient and healthcare provider collaborations, as well as practice and system level enhancements to support sustainability of deprescribing practices.
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Affiliation(s)
- Natalie Kennie-Kaulbach
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | | | - Olga Kits
- Research Methods Unit, Research & Innovation, Nova Scotia Health Authority, Halifax, NS, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
- Geriatric Medicine Research, Faculty of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, NS, Canada
| | | | | | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
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Juul-Larsen HG, Christensen LD, Bandholm T, Andersen O, Kallemose T, Jørgensen LM, Petersen J. Patterns of Multimorbidity and Differences in Healthcare Utilization and Complexity Among Acutely Hospitalized Medical Patients (≥65 Years) - A Latent Class Approach. Clin Epidemiol 2020; 12:245-259. [PMID: 32184671 PMCID: PMC7053819 DOI: 10.2147/clep.s226586] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/12/2019] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The majority of acutely admitted older medical patients are multimorbid, receive multiple drugs, and experience a complex treatment regime. To be able to optimize treatment and care, we need more knowledge of the association between different patterns of multimorbidity and healthcare utilization and the complexity thereof. The purpose was therefore to investigate patterns of multimorbidity in a Danish national cohort of acutely hospitalized medical patients aged 65 and older and to determine the association between these multimorbid patterns with the healthcare utilization and complexity. PATIENTS AND METHODS Longitudinal cohort study of 129,900 (53% women) patients. Latent class analysis (LCA) was used to develop patterns of multimorbidity based on 22 chronic conditions ascertained from Danish national registers. A latent class regression was used to test for differences in healthcare utilization and healthcare complexity among the patterns measured in the year leading up to the index admission. RESULTS LCA identified eight distinct multimorbid patterns. Patients belonging to multimorbid patterns including the major chronic conditions; diabetes and chronic obstructive pulmonary disease was associated with higher odds of healthcare utilization and complexity than the reference pattern ("Minimal chronic conditions"). The pattern with the highest number of chronic conditions did not show the highest healthcare utilization nor complexity. CONCLUSION Our study showed that chronic conditions cluster together and that these patterns differ in healthcare utilization and complexity. Patterns of multimorbidity have the potential to be used in epidemiological studies of healthcare planning but should be confirmed in other population-based studies.
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Affiliation(s)
- Helle Gybel Juul-Larsen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Line Due Christensen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Research Unit for General Practice, Aarhus, Denmark
| | - Thomas Bandholm
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Ove Andersen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Emergency Department, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lillian Mørch Jørgensen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Emergency Department, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Janne Petersen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Centre for Clinical Research and Prevention, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M, Gnjidic D. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol 2020; 13:233-245. [PMID: 32056451 DOI: 10.1080/17512433.2020.1730812] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.
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Affiliation(s)
- Mouna Sawan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, St Leonards, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Justin Turner
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, Australia
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Kouladjian O’Donnell L, Sawan M, Reeve E, Gnjidic D, Chen TF, Kelly PJ, Bell JS, Hilmer SN. Implementation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© into home medicines review: a protocol for a cluster-randomised clinical trial in older adults. BMC Geriatr 2020; 20:51. [PMID: 32050899 PMCID: PMC7017507 DOI: 10.1186/s12877-020-1442-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/23/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Older people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes. METHODS This study consists of 2 stages: Stage I - a two-arm parallel-group cluster-randomised clinical trial, and Stage II - process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients' goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient's GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS). OUTCOMES The primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR. DISCUSSION This study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults. TRIAL REGISTRATION The trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.
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Affiliation(s)
- Lisa Kouladjian O’Donnell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
| | - Mouna Sawan
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
- 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, Saskatchewan, Canada
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, South Australia Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW Australia
| | - Timothy F. Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Patrick J. Kelly
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - J. Simon Bell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria Australia
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria Australia
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia Australia
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
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Dumitrescu I, Casteels M, De Vliegher K, Dilles T. High-risk medication in community care: a scoping review. Eur J Clin Pharmacol 2020; 76:623-638. [PMID: 32025751 DOI: 10.1007/s00228-020-02838-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care. METHODS Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions. RESULTS Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care. CONCLUSION The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.
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Affiliation(s)
- Irina Dumitrescu
- Department of Nursing Science and Midwifery, Centre For Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium. .,White-Yellow Cross of Flanders, Brussels, Belgium.
| | - Minne Casteels
- White-Yellow Cross of Flanders, Brussels, Belgium.,Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | | | - Tinne Dilles
- Department of Nursing Science and Midwifery, Centre For Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Rivera J, Shcherbakova N, Vala C, Capoccia K. Community pharmacists' interventions and documentation during medication therapy management encounters delivered face-to-face versus via telephone: The devil is in the details. Res Social Adm Pharm 2020; 16:1447-1451. [PMID: 31889640 DOI: 10.1016/j.sapharm.2019.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/21/2019] [Accepted: 12/22/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND To date, no studies are available comparing in-person versus telephone-administered medication therapy management (MTM) encounters in a community pharmacy setting with respect to medication-related problems, interventions and documentation. OBJECTIVE The objective of this study was to evaluate types of medication-related problems, interventions, and documentation among patients receiving MTM face-to-face versus over the telephone. METHODS A retrospective analysis was performed on all completed comprehensive medication reviews (CMR) between 2011 and 2017 in 14 community pharmacies in Western Massachusetts, USA that belong to one district of a national chain. Medication-related problems were classified as: Beers criteria medications, untreated condition, dose too high or low, medication omission, duplicate therapy, drug-drug interaction, non-adherence, complicated dosing. Pharmacist's interventions were classified as education, medication reconciliation, and vaccination. Documentation of assessment, plan, discussion notes, and recommendations were evaluated as being present or absent. RESULTS In total, 297 encounters (56.5% were over the telephone) were included in the analysis. There was no significant differences between clinical and demographic characteristics and types of medication-related problems and pharmacist interventions among patients who received face-to-face versus telephone MTM service. Assessment was documented among 28% of face-to-face and 42% of telephone CMR encounters (p < 0.05). Plan was documented among 27% of face-to-face and 40% of telephone CMR encounters (p < 0.05). Discussion notes were documented among 97% of face-to-face and 98% of telephone CMR encounters (p > 0.05). Pharmacist recommendations were documented among 92% of face-to-face and 95% of telephone CMR encounters (p > 0.05). CONCLUSIONS Pharmacists identify medication-related problems and provide education and medication reconciliation interventions independent of the mode of delivery. The overall low frequency of assessment and plan documentation raises concerns. It is imperative for pharmacists to document both instances of provider outreach and follow-up to ascertain resolutions of patients' medication-related problems.
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Affiliation(s)
| | - Natalia Shcherbakova
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA.
| | | | - Kam Capoccia
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA
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Zimmerman KM, Bell CA, Donohoe KL, Salgado TM. Medicine, pharmacy and nursing trainees' perceptions of curriculum preparation to deprescribe and interprofessional roles in the deprescribing process. GERONTOLOGY & GERIATRICS EDUCATION 2020; 41:63-84. [PMID: 31488030 DOI: 10.1080/02701960.2019.1661840] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
With increasing rates of polypharmacy among older adults, preparedness of current and future health care professionals to identify and deprescribe potentially inappropriate medications (PIMs) is critical. Medicine (n = 28), pharmacy (n = 35) and nursing (n = 11) trainees enrolled in an interprofessional course completed a survey assessing preparedness, confidence and attitudes toward deprescribing, and perception of interprofessional roles in the process. Pharmacy (p = .001) and nursing (p = .007) felt that their curriculum prepared them better to identify and deprescribe PIMs compared to medicine trainees. Pharmacy trainees perceived significantly more barriers to deprescribing compared to medicine (p = .003), but not nursing trainees. Physicians and pharmacists were perceived as the main drivers of the deprescribing process. Current curricular content should be modified to address lack of preparedness to deprescribe in clinical practice. Addressing such gaps as part of an interprofessional team may increase interprofessional role recognition and translate into changes in clinical practice as trainees move into the workforce.
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Affiliation(s)
- Kristin M Zimmerman
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Courtney A Bell
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Krista L Donohoe
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Teresa M Salgado
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
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Zimmerman KM, Linsky AM, Donohoe KL, Hobgood SE, Sargent L, Salgado TM. An Interprofessional Workshop to Enhance De-prescribing Practices Among Health Care Providers. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2020; 40:49-57. [PMID: 32149948 DOI: 10.1097/ceh.0000000000000280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION De-prescribing is a complex behavior that benefits from a multifaceted approach to learning. We sought to create and deliver a 1-day interprofessional workshop to enhance de-prescribing knowledge and skills among health care professionals. METHODS Workshop development was based on the Adult Learning Theory and the Theoretical Domains Framework. The workshop addressed provider-related barriers, was created and delivered by an interprofessional team, and combined didactic and active learning techniques. Targeted participants included physicians, advanced practice providers (nurse practitioners and physician's assistants), pharmacists, and clinic staff. Interprofessional workgroups were created a priori. Participants were asked to complete a postprogram evaluation, including whether they would implement changes to practice, teaching, research, or administrative duties after participation. RESULTS We created an in-person, 5.5 credit hour, interprofessional de-prescribing workshop that comprised six sessions: (1) polypharmacy and de-prescribing overview; (2) identification of potentially inappropriate medications; (3) prioritization of medications for de-prescribing; (4) design and implementation of a de-prescribing plan; (5) principles for a patient-centered approach; and (6) suggestions for successful collaboration. Forty-one participants attended the workshop, and 38 (92.7%) completed the postprogram assessment. Participants felt they were likely to implement changes in practice, teaching, research, or administrative duties, rating themselves with a mean of 9.2 (SD = 1.06) on a 1 to 10 scale. Ultimately, 96.6% would recommend the workshop to others. DISCUSSION Based on participant feedback, the workshop catalyzed intention to change practice, teaching, research, or administrative duties. Other institutions seeking to change the complex behavior of de-prescribing may wish to model this development and delivery strategy.
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Affiliation(s)
- Kristin M Zimmerman
- Mrs. Zimmerman: Associate Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA. Dr. Linsky: Assistant Professor, VA Boston Healthcare System, Department of Medicine, Center for Healthcare Organization and Implementation Research, and Assistant Professor, Boston University School of Medicine, Boston, MA. Dr. Donohoe: Associate Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA. Dr. Hobgood: Associate Professor, Department of Internal Medicine, Division of Geriatric Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. Dr. Sargent: Assistant Professor, Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, VA. Dr. Salgado: Assistant Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
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Umek W, Gleiss A, Bodner-Adler B, Reichardt B, Rinner C, Heinze G. The role of prescription drugs in female overactive bladder syndrome-A population-wide cohort study. Pharmacoepidemiol Drug Saf 2019; 29:189-198. [PMID: 31808271 PMCID: PMC7027558 DOI: 10.1002/pds.4920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 09/13/2019] [Accepted: 10/12/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE Overactive bladder (OAB) syndrome has severe effects on quality of life. Certain drugs are known risk factors for OAB but have not been investigated in a population-wide cohort. The objective of this study was to investigate the role of prescription drugs in the etiology of the OAB. METHODS Retrospective cohort study using a population-wide database of 4 185 098 OAB-naïve women followed Strengthening the Reporting of Observational Studies in Epidemiology guidelines. We investigated the subscription use of anticholinergic medication and 188 chemical substances, which are suspected triggers for OAB (trigger medications [TMs]). We hypothesized a relationship between the prescription for one or more TM and the prescription for anticholinergic medication against OAB (marker medication [MM]). RESULTS The use of MM in Austria increased from 2009 to 2012 on average by 0.025 percentage points per year (95% confidence interval [CI]: 0.015-0.036). In December 2012, 1 in 123 women filled a prescription for any MM, equaling an average utilization of 0.84%. The relative risk of filling a prescription for a MM 6 months after filling a prescription for a TM was 2.70 (95% CI: 2.64-2.77). All investigated medication classes showed a higher risk for the prescription for MM. Medication from classes "genitourinary system and sex hormones" and "systemic anti-infectives" caused the highest increase in risk (109% and 89%, respectively). Prescriptions for class "cardiovascular system" caused the lowest increase in the risk (15%). CONCLUSION Certain prescription medications are a significant risk factor for the need to take anticholinergic medication as a consequence.
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Affiliation(s)
- Wolfgang Umek
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner Institute of Specialised Gynecology and Obstetrics, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
| | - Barbara Bodner-Adler
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Berthold Reichardt
- Sickness Fund Burgenland, Burgenlaendische Gebietskrankenkasse, Eisenstadt, Austria
| | - Christoph Rinner
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
| | - Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
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Kua CH, Mak VS, Lee SWH. Perspectives of health professionals towards deprescribing practice in Asian nursing homes: a qualitative interview study. BMJ Open 2019; 9:e030106. [PMID: 31604786 PMCID: PMC6797246 DOI: 10.1136/bmjopen-2019-030106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To examine the determinants of deprescribing among health professionals in nursing homes, focusing on knowledge, practice and attitude. DESIGN This was a qualitative study comprising semi-structured face-to-face interviews guided by 10 open-ended questions. Interviews were conducted until data saturation was achieved and no new ideas were formed. The interviews were audio-recorded, transcribed verbatim and analysed for themes. To derive themes, we employed directed content analysis of transcript data. Coding was completed using a combination of open, axial and selective coding. SETTING Four nursing homes in Singapore. PARTICIPANTS The study involved 17 participants (comprising 4 doctors, 4 pharmacists and 9 nurses). RESULTS Two key themes were identified, enablers and challenges. These were enablers and challenges faced by doctors, pharmacists and nurses towards deprescribing. The identified subthemes for enablers of deprescribing were: (1) awareness of medications that are unnecessary or could be targeted for deprescribing; (2) improving quality of life for patients with limited life expectancy; (3) improving communication between doctors, pharmacists and nurses; (4) systematic deprescribing practice and educational tools and (5) acknowledgement of possible benefits of deprescribing. The identified subthemes for challenges of deprescribing were: (1) symptoms not acknowledged as possibly drug-related; (2) lack of knowledge in patient's and family members' preferences; (3) lack of coordination between health professionals in hospitals and nursing homes and (4) limited tools for deprescribing. The development of a local guideline, mentoring nurses, case discussions, better shared decision-making and improving multidisciplinary communication, may help to support the process of deprescribing. CONCLUSION In conclusion, this study highlighted that deprescribing in the nursing homes is perceived by health professionals to be challenging and future research could assess how routine case studies, mentoring and better multidisciplinary communication could improve deprescribing knowledge and process in the nursing homes.
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Affiliation(s)
- Chong-Han Kua
- School of Pharmacy, Monash University-Malaysia Campus, Bandar Sunway, Malaysia
- Continuing and Community Care Department, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vivienne Sl Mak
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University-Parkville Campus, Parkville, Victoria, Australia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University-Malaysia Campus, Bandar Sunway, Malaysia
- School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
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Verdoorn S, Blom J, Vogelzang T, Kwint HF, Gussekloo J, Bouvy ML. The use of goal attainment scaling during clinical medication review in older persons with polypharmacy. Res Social Adm Pharm 2019; 15:1259-1265. [DOI: 10.1016/j.sapharm.2018.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/28/2018] [Accepted: 11/02/2018] [Indexed: 12/19/2022]
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Baysari MT, Duong M, Zheng WY, Nguyen A, Lo S, Ng B, Ritchie A, Le Couteur D, McLachlan A, Bennett A, Hilmer S. Delivering the right information to the right person at the right time to facilitate deprescribing in hospital: a mixed methods multisite study to inform decision support design in Australia. BMJ Open 2019; 9:e030950. [PMID: 31562155 PMCID: PMC6773288 DOI: 10.1136/bmjopen-2019-030950] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To inform the design of electronic decision support (EDS) to facilitate deprescribing in hospitals we set out to (1) explore the current processes of in-hospital medicines review, deprescribing and communication of deprescribing decisions with the patient's general practitioner (GP), (2) identify barriers to undertaking these tasks and (3) determine user preferences for EDS. DESIGN Multimethod, multisite study comprising observations, semistructured interviews and focus groups. SETTING General medicine, geriatric medicine and rehabilitation wards at six hospitals in two local health districts in Sydney, Australia and primary care practices in one primary healthcare district in Sydney, Australia. PARTICIPANTS 149 participants took part in observations, interviews and focus groups, including 69 hospital doctors, 13 nurses, 55 pharmacists and 12 GPs. MAIN OUTCOME MEASURES Observational data on who was involved in medicines review and deprescribing, when medicines review took place, and what artefacts (eg, forms) were used. Participants reported perceptions of medicines review, polypharmacy and deprescribing and preferences for EDS. RESULTS Deprescribing, undertaken during medicines review, was typically performed by a junior doctor, following a decision to deprescribe by a senior doctor. Key barriers to deprescribing included a perception that deprescribing was not the responsibility of hospital doctors, a lack of confidence among junior doctors and pharmacists in broaching this topic with senior doctors and a lack of patient engagement in the deprescribing process. In designing EDS, the tools, likely to be used by junior doctors, pharmacists and nurses, should be available throughout the hospitalisation and should comprise non-interruptive evidence-based guidance on why and how to deprescribe. CONCLUSIONS Deprescribing decisions are complex and influenced by multiple factors. The implementation of EDS alone is unlikely to address all barriers identified. To achieve sustained improvements in monitoring of polypharmacy and subsequent deprescribing, a multifaceted intervention is needed.
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Affiliation(s)
- Melissa T Baysari
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Mai Duong
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
| | - Wu Yi Zheng
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Amy Nguyen
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sarita Lo
- Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
| | - Brendan Ng
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, New South Wales, Australia
- Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David Le Couteur
- University of Sydney Centre for Education and Research on Ageing, Concord, New South Wales, Australia
| | - Andrew McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Sarah Hilmer
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Gillespie R, Mullan J, Harrison L. Deprescribing for older adults in Australia: factors influencing GPs. Aust J Prim Health 2019; 24:463-469. [PMID: 30423283 DOI: 10.1071/py18056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/17/2018] [Indexed: 12/24/2022]
Abstract
Polypharmacy is increasing among older Australians, raising their risk of experiencing medication-related harm. As part of the prescribing continuum, deprescribing is a strategy proposed to reduce inappropriate polypharmacy. This study explored factors that influence deprescribing among Australian GPs using a new 21-item survey to measure GP attitudes and practices. The 85 GP responses indicated that many factors are supportive of deprescribing. GPs suggest that they are willing to explore their older patients' deprescribing preferences; they believe that they have enough information about the potential harms and benefits of medication to inform their deprescribing decisions and are confident to communicate this information to their patients. GPs did not consider their patients would interpret deprescribing as being 'given up on'. Limited time to review medications, poor communication between prescribers and a perception that other prescribers do not respect their role as overall coordinators of their older patients' medications were considered by respondents to be unsupportive of deprescribing. Overall, despite GPs reporting many supportive factors for deprescribing, the influence of unsupportive factors appears to remain strong, as deprescribing is not routinely considered in practice.
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Affiliation(s)
- Robyn Gillespie
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Judy Mullan
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia
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Wouters H, Foster JM, Ensink A, O’Donnell LK, Zuidema SU, Boersma F, Taxis K. Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study. Front Pharmacol 2019; 10:1026. [PMID: 31619991 PMCID: PMC6759938 DOI: 10.3389/fphar.2019.01026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/12/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Juliet M. Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Anne Ensink
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Lisa Kouladjian O’Donnell
- NHMRC Cognitive Partnership Centre, University of Sydney, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Sytse U. Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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Wouters H, Foster JM, Ensink A, O'Donnell LK, Zuidema SU, Boersma F, Taxis K. Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study. Front Pharmacol 2019. [PMID: 31619991 DOI: 10.3389/fphar.2019.01026/full] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Juliet M Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Anne Ensink
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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Sawan M, Kouladjian O’Donnell L, Hilmer SN. Perspectives of residential aged care facilities' staff on the identification and recording of residents' medication‐related goals of care. Australas J Ageing 2019; 39:e134-e144. [DOI: 10.1111/ajag.12714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Mouna Sawan
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research Royal North Shore Hospital Sydney NSW Australia
| | - Lisa Kouladjian O’Donnell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research Royal North Shore Hospital Sydney NSW Australia
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health University of Sydney Sydney NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research Royal North Shore Hospital Sydney NSW Australia
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Clough AJ, Hilmer SN, Kouladjian‐O'Donnell L, Naismith SL, Gnjidic D. Health professionals' and researchers' opinions on conducting clinical deprescribing trials. Pharmacol Res Perspect 2019; 7:e00476. [PMID: 31049205 PMCID: PMC6482940 DOI: 10.1002/prp2.476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/16/2022] Open
Abstract
While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.
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Affiliation(s)
- Alexander J. Clough
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sarah N. Hilmer
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Lisa Kouladjian‐O'Donnell
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sharon L. Naismith
- Brain & Mind CentreUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
| | - Danijela Gnjidic
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
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