1
|
Quek HW, Page A, Lee K, Lee G, Hawthorne D, Clifford R, Potter K, Etherton-Beer C. The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis. Br J Clin Pharmacol 2024; 90:2409-2482. [PMID: 39164070 DOI: 10.1111/bcp.16200] [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: 10/06/2023] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 08/22/2024] Open
Abstract
AIMS Previous systematic reviews suggest that deprescribing may improve survival, particularly in frail older people. Evidence is rapidly accumulating, suggesting a need for an updated review of the literature. METHODS We updated a 2016 systematic review and meta-analysis to include studies published from inception to 26 April 2024 from specified databases. Studies in which older people had at least one medication deprescribed were included and grouped by study designs and targeted medications. The risk of bias was assessed using the Cochrane tool and the Newcastle-Ottawa tool. Odds ratios (OR) or mean differences were calculated as the effect measures using either the Mantel-Haenszel or generic inverse-variance method with fixed- or random-effects meta-analyses. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, physical health, cognitive function, quality of life and effect on medication regimen. Subgroup analyses were performed based on age and intervention types. RESULTS A total of 259 studies (reported in 286 papers) were included in this updated review. Deprescribing polypharmacy did not result in a significant reduction in mortality in both randomized (OR 0.96, 95% confidence interval [CI] 0.84-1.09) and non-randomized studies (OR 0.70, 95% CI 0.36-1.38). Further subgroup analyses of randomized studies on deprescribing polypharmacy demonstrated a significant reduction in mortality in the young old (aged 65-79) (OR 0.71, 95% CI 0.51-0.99) and when patient-specific interventions were applied (OR 0.79, 95% CI 0.63-0.99). CONCLUSIONS Deprescribing can be achieved with potentially important benefits in terms of improved survival, particularly when patient-specific interventions are applied and initiated early in the young old.
Collapse
Affiliation(s)
- Hui Wen Quek
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Amy Page
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Kenneth Lee
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Georgie Lee
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Deborah Hawthorne
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Rhonda Clifford
- School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Christopher Etherton-Beer
- Western Australian Centre for Health and Ageing, The University of Western Australia and Royal Perth Hospital, Perth, Western Australia, Australia
| |
Collapse
|
2
|
Liu F. Data Science Methods for Real-World Evidence Generation in Real-World Data. Annu Rev Biomed Data Sci 2024; 7:201-224. [PMID: 38748863 DOI: 10.1146/annurev-biodatasci-102423-113220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024]
Abstract
In the healthcare landscape, data science (DS) methods have emerged as indispensable tools to harness real-world data (RWD) from various data sources such as electronic health records, claim and registry data, and data gathered from digital health technologies. Real-world evidence (RWE) generated from RWD empowers researchers, clinicians, and policymakers with a more comprehensive understanding of real-world patient outcomes. Nevertheless, persistent challenges in RWD (e.g., messiness, voluminousness, heterogeneity, multimodality) and a growing awareness of the need for trustworthy and reliable RWE demand innovative, robust, and valid DS methods for analyzing RWD. In this article, I review some common current DS methods for extracting RWE and valuable insights from complex and diverse RWD. This article encompasses the entire RWE-generation pipeline, from study design with RWD to data preprocessing, exploratory analysis, methods for analyzing RWD, and trustworthiness and reliability guarantees, along with data ethics considerations and open-source tools. This review, tailored for an audience that may not be experts in DS, aspires to offer a systematic review of DS methods and assists readers in selecting suitable DS methods and enhancing the process of RWE generation for addressing their specific challenges.
Collapse
Affiliation(s)
- Fang Liu
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, Indiana, USA;
| |
Collapse
|
3
|
Strayer TE, Hollingsworth EK, Shah AS, Vasilevskis EE, Simmons SF, Mixon AS. Why do older adults decline participation in research? Results from two deprescribing clinical trials. Trials 2023; 24:456. [PMID: 37464431 PMCID: PMC10353211 DOI: 10.1186/s13063-023-07506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Heterogenous older adult populations are underrepresented in clinical trials, and their participation is necessary for interventions that directly target them. The purpose of this study was to evaluate reasons why hospitalized older adults declined participation in two deprescribing clinical trials. METHODS We report enrollment data from two deprescribing trials, Shed-MEDS (non-Veterans) and VA DROP (Veterans). For both trials, inclusion criteria required participants to be hospitalized, age 50 or older, English-speaking, and taking five or more home medications. Eligible patients were approached for enrollment while hospitalized. When an eligible patient or surrogate declined participation, the reason(s) were recorded and subsequently analyzed inductively to develop themes, and a chi-square test was used for comparison (of themes between Veterans and non-Veterans). RESULTS Across both trials, 1226 patients (545 non-Veterans and 681 Veterans) declined enrollment and provided reasons, which were condensed into three themes: (1) feeling overwhelmed by their current health status, (2) lack of interest or mistrust of research, and (3) hesitancy to participate in a deprescribing study. A greater proportion of Veterans expressed a lack of interest or mistrust in research (42% vs 26%, chi-square value = 36.72, p < .001), whereas a greater proportion of non-Veterans expressed feeling overwhelmed by their current health status (54% vs 35%, chi-square value = 42.8 p < 0.001). Across both trials, similar proportion of patients expressed hesitancy to participate in a deprescribing study, with no significant difference between Veterans and non-Veterans (23% and 21%). CONCLUSIONS Understanding the reasons older adults decline participation can inform future strategies to engage this multimorbid population.
Collapse
Affiliation(s)
- Thomas E Strayer
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
| | - Emily K Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
| | - Avantika S Shah
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
| | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
| | - Amanda S Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
| |
Collapse
|
4
|
Mejías-Trueba M, Rodríguez-Pérez A, García-Cabrera E, Jiménez-Juan C, Sánchez-Fidalgo S. The Barriers to Deprescription in Older Patients: A Survey of Spanish Clinicians. Healthcare (Basel) 2023; 11:1879. [PMID: 37444713 DOI: 10.3390/healthcare11131879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/15/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVE There are barriers to deprescription that hinder its implementation in clinical practice. The objective of this study was to analyse the main barriers and limitations of the deprescription process perceived by physicians who care for multipathological patients. MATERIALS AND METHODS The "deprescription questionnaire of elderly patients" was adapted to an online format and sent to physicians in geriatrics. Question 1 is a reference to establish agreement or disagreement with this practice. The influence of different aspects of deprescription was analysed via the demographic characteristics of the clinicians and perceptions of the various barriers (questions 2-9) by means of bivariate analysis. Based on the latter, a multivariate model was carried out to demonstrate the relationship between barriers and the degree of deprescription agreement among respondents. RESULTS Of the 72 respondents, 72.2% were in favour of deprescribing. Regarding the analyses, the demographic characteristics did not influence rankings. The deprescription of preventive drugs and consensus with patients were associated with a positive attitude towards deprescribing, while withdrawing drugs prescribed by other professionals, time constraints and patient reluctance emerged as possible barriers. The only factor independently associated with deprescribing was lack of time. CONCLUSIONS Time was found to be the main barrier to deprescription. Training, the creation of multidisciplinary teams and integrated health systems are key facilitators.
Collapse
Affiliation(s)
- Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
- Departamento de Enfermedades Infecciosas, Microbiología y Parasitología, Grupo de Investigación en Enfermedades Infecciosas, Instituto de Biomedicina de Sevilla, Universidad de Sevilla/Consejo Superior de Investigaciones Científicas/Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, 28029 Madrid, Spain
| | - Aitana Rodríguez-Pérez
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
| | - Emilio García-Cabrera
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, 41009 Sevilla, Spain
| | - Carlos Jiménez-Juan
- Unidad de Gestión Clínica Medicina Interna, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
| | - Susana Sánchez-Fidalgo
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, 41009 Sevilla, Spain
| |
Collapse
|
5
|
Mejías-Trueba M, Rodríguez-Pérez A, Hernández-Quiles C, Ollero-Baturone M, Nieto-Martín MD, Sánchez-Fidalgo S. Feasibility of the Implementation of LESS-CHRON in Clinical Practice: A Pilot Intervention Study in Older Patients With Multimorbidity. Innov Aging 2023; 7:igad042. [PMID: 37360215 PMCID: PMC10289520 DOI: 10.1093/geroni/igad042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Indexed: 06/28/2023] Open
Abstract
Background and Objectives Potentially inappropriate medication refers to the prescription of drugs whose risks outweigh the benefits. There are different pharmacotherapeutic optimization strategies to detect and avoid potentially inappropriate medications (PIMs), namely deprescription. The List of Evidence-Based Deprescribing for Chronic Patients (LESS-CHRON) criteria were designed as a tool to systematize the deprescribing process. LESS-CHRON has established itself as one of the most suitable to be applied in older (≥65 years) multimorbid patients. However, it has not been applied to these patients, to measure the impact on their treatment. For this reason, a pilot study was conducted to analyze the feasibility of implementing this tool in a care pathway. Research Design and Methods A pre-post quasi-experimental study was conducted. Older outpatients with multimorbidity from the Internal Medicine Unit of a benchmark Hospital were included. The main variable was feasibility in clinical practice, understood as the likelihood that the deprescribing intervention recommended by the pharmacist would be applied to the patient. Success rate, therapeutic, and anticholinergic burden, and other variables related to health care utilization were analyzed. Results A total of 95 deprescribing reports were prepared. Forty-three were evaluated by the physician who assessed the recommendations made by pharmacists. This translates into an implementation feasibility of 45.3%. The application of LESS-CHRON identified 92 PIMs. The acceptance rate was 76.7% and after 3 months 82.7% of the stopped drugs remained deprescribed. A reduction in anticholinergic burden and enhanced adherence was achieved. However, no improvement was found in clinical or health care utilization variables. Discussion and Implications The implementation of the tool in a care pathway is feasible. The intervention has achieved great acceptance and deprescribing has been successful in a not insignificant percentage. Future studies with a larger sample size are necessary to obtain more robust results in clinical and health care utilization variables.
Collapse
Affiliation(s)
- Marta Mejías-Trueba
- Department of Pharmacy, University Hospital Virgen del Rocio, Seville, Spain
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/Spanish National Research Council/University Hospital Virgen del Rocio, Seville, Spain
| | | | | | | | | | - Susana Sánchez-Fidalgo
- Department of Preventive Medicine and Public Health, University of Seville, Sevilla, Spain
| |
Collapse
|
6
|
Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Kripalani S, Mixon AS, Simmons SF. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023; 183:223-231. [PMID: 36745422 PMCID: PMC9989899 DOI: 10.1001/jamainternmed.2022.6545] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. Objective To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. Design, Setting, and Participants This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. Interventions The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. Main Outcomes and Measures The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. Results A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Conclusions and Relevance Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02979353.
Collapse
Affiliation(s)
- Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Sunil Kripalani
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S. Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
7
|
Keller MS, Carrascoza-Bolanos J, Breda K, Kim LY, Kennelty KA, Leang DW, Murry LT, Nuckols TK, Schnipper JL, Pevnick JM. Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study. BMJ Open 2023; 13:e066234. [PMID: 36813499 PMCID: PMC9950911 DOI: 10.1136/bmjopen-2022-066234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. DESIGN We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. SETTING Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. PARTICIPANTS Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. RESULTS We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. CONCLUSIONS While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.
Collapse
Affiliation(s)
- Michelle S Keller
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Health Policy and Management, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Kathleen Breda
- Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Linda Y Kim
- Nursing, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Korey A Kennelty
- College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
| | - Donna W Leang
- Pharmacy, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Logan T Murry
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, Iowa, USA
| | - Teryl K Nuckols
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joshua M Pevnick
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
8
|
Lee S, Bobb Swanson M, Fillman A, Carnahan RM, Seaman AT, Reisinger HS. Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study. J Am Geriatr Soc 2023; 71:62-76. [PMID: 36258309 PMCID: PMC10092723 DOI: 10.1111/jgs.18047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed. METHODS We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes. RESULTS Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations. CONCLUSIONS Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.
Collapse
Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Allison Fillman
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Aaron T Seaman
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
9
|
DiConti-Gibbs A, Chen KY, Coffey CE. Polypharmacy in the Hospitalized Older Adult. Clin Geriatr Med 2022; 38:667-684. [DOI: 10.1016/j.cger.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
10
|
Turk A, Wong G, Mahtani KR, Maden M, Hill R, Ranson E, Wallace E, Krska J, Mangin D, Byng R, Lasserson D, Reeve J. Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 2022; 20:297. [PMID: 36042454 PMCID: PMC9429627 DOI: 10.1186/s12916-022-02475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. METHODS The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. RESULTS We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. CONCLUSION Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.
Collapse
Affiliation(s)
- Amadea Turk
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Michelle Maden
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ruaraidh Hill
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ed Ranson
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Emma Wallace
- Department of General Practice RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, L8P 1H6, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, PL4 8AA, UK
| | - Daniel Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK.
| |
Collapse
|
11
|
Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 PMCID: PMC9376985 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | |
Collapse
|
12
|
McCarthy M, Mak S, Kaufmann CN, Lum HD, Fung CH. Care coordination needs for deprescribing benzodiazepines and benzodiazepine receptor agonists. Res Social Adm Pharm 2022; 18:2691-2694. [PMID: 34229951 PMCID: PMC8720104 DOI: 10.1016/j.sapharm.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
Deprescribing of medications such as benzodiazepines and benzodiazepine receptor agonists (z-drugs) can be a complex process that varies across practices, specialties, and health care systems. Care coordination among healthcare providers, patients, families, and other healthcare system components is critical to achieving high levels of deprescribing and person-centered care. We present a framework for promoting care coordination in the context of benzodiazepine/z-drug deprescribing. Future efforts are needed to study the impact of better care coordination on benzodiazepines/z-drug discontinuation and other outcomes that are important to stakeholders.
Collapse
Affiliation(s)
- Michaela McCarthy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, Denver, CO,College of Nursing, University of Colorado, Aurora, CO
| | - Selene Mak
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Christopher N. Kaufmann
- Division of Epidemiology and Data Science in Gerontology, Department of Aging and Geriatric Research, University of Florida, Gainesville, FL
| | - Hillary D. Lum
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Health Care System, Aurora, CO,Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Constance H. Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
13
|
González-Bueno J, Sevilla-Sánchez D, Puigoriol-Juvanteny E, Molist-Brunet N, Codina-Jané C, Espaulella-Panicot J. Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity. Eur J Clin Pharmacol 2021; 78:127-137. [PMID: 34448906 DOI: 10.1007/s00228-021-03207-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity. METHODS Uncontrolled before-after study in an intermediate care facility in a mixed urban-rural district. Inpatients aged ≥ 65 years with multimorbidity exposed to polypharmacy before hospital admission were consecutively enrolled. Every patient's treatment plan was analyzed through the PCP model, which includes interventions aimed at improving medication adherence. The primary endpoint was the change in the proportion of adherent patients between pre-admission and after discharge for all regularly scheduled long-term medications, using the proportion of days covered (PDC). Secondary endpoints included the change on mean PDC for all long-term medications, number of long-term medications, proportion of patients with hyperpolypharmacy, medication regimen complexity index (MRCI) score, drug burden index (DBI) score, number of potential inappropriate prescribing (PIP), and proportion of patients with ≥ 2 PIPs. RESULTS Ninety-three non-institutionalized patients were included (mean age 83.0 ± SD 6.1 years). The proportion of adherent patients increased from 22.1 to 51.9% (P < 0.001). Intervention also improved mean PDC [mean difference (95% CI) 10.6 (7.7, 13.5)] and effective prescribing through a reduction on the number of long-term medications [- 1.3 (- 1.7, - 0.9)], proportion of patients exposed to hyperpolypharmacy (- 16.1%, P < 0.001), MRCI score [- 2.2 (- 3.4, - 1.0)], DBI score [- 0.16 (- 1.8, - 1.3)], number of PIPs [- 1.6 (- 1.8, - 1.3)], and proportion of patients with ≥ 2 PIPs (- 53.7%, P < 0.001). CONCLUSION Studied intervention provides significant effective prescribing and medication adherence enhancements in non-institutionalized older patients with multimorbidity and polypharmacy.
Collapse
Affiliation(s)
- J González-Bueno
- Pharmacy Department, Consorci Hospitalari de Vic, Vic, Barcelona, Spain. .,Central Catalonia Chronicity Research Group (C3RG), University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain.
| | - D Sevilla-Sánchez
- Central Catalonia Chronicity Research Group (C3RG), University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain.,Pharmacy Department, Parc Sanitari Pere Virgili, Barcelona, Spain
| | - E Puigoriol-Juvanteny
- Epidemiology Unit, Consorci Hospitalari de Vic, Vic, Barcelona, Spain.,Tissue Repair and Regeneration Laboratory (TR2Lab) Group, Faculty of Sciences and Technology & Faculty of Medicine, University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain
| | - N Molist-Brunet
- Central Catalonia Chronicity Research Group (C3RG), University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain.,Department of Geriatrics, Consorci Hospitalari de Vic & Fundació Hospital de La Santa Creu de Vic, Vic, Barcelona, Spain
| | - C Codina-Jané
- Pharmacy Department, Consorci Hospitalari de Vic, Vic, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain
| | - J Espaulella-Panicot
- Central Catalonia Chronicity Research Group (C3RG), University of Vic - Central University of Catalonia (UVIC-UCC), Vic, Barcelona, Spain.,Department of Geriatrics, Consorci Hospitalari de Vic & Fundació Hospital de La Santa Creu de Vic, Vic, Barcelona, Spain
| |
Collapse
|
14
|
Using Deprescribing Practices and the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria to Reduce Harm and Preventable Adverse Drug Events in Older Adults. J Patient Saf 2021; 16:S23-S35. [PMID: 32809998 PMCID: PMC7447181 DOI: 10.1097/pts.0000000000000747] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Supplemental digital content is available in the text. Objectives Approximately 98% of older Americans are simultaneously taking 5—or more—medications to manage at least 2 chronic conditions. Polypharmacy and the use of potentially inappropriate medications (PIMs) are a concern for older adults because they pose a risk for adverse drug events (ADEs), which are associated with emergency department visits and hospitalizations and are an important patient safety priority. We sought to review the evidence of patient safety practices aimed at reducing preventable ADEs in older adults, specifically (i) deprescribing interventions to reduce polypharmacy and (ii) use of the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) to reduce PIMs. Methods We conducted a systematic review of literature published between 2008 and 2018 that studied examined the effect of these interventions to reduce preventable ADEs in older adults. Results Twenty-six studies and 1 systematic review were included (14 for deprescribing and 12 for STOPP and the systematic review). The deprescribing interventions involved decision support tools, educational interventions, and medication reviews by pharmacists and/or providers. Deprescribing studies primarily examined the effect of interventions on process outcomes and observed reductions in polypharmacy, often significantly. A few studies also examined clinical and economic outcomes. Studies of the use of the STOPP screening criteria most commonly reported changes in PIMs, as well as some economic outcomes. Conclusions Deprescribing interventions and interventions using the STOPP criteria seem effective in reducing polypharmacy and PIMs in older adults, respectively. Future research on the effectiveness of these approaches on clinical outcomes, the comparative effectiveness of different multicomponent interventions using these approaches, and how to most effectively implement them to improve uptake and evidence-based care is needed.
Collapse
|
15
|
Weir KR, Naganathan V, Carter SM, Tam CWM, McCaffery K, Bonner C, Rigby D, McLachlan AJ, Jansen J. The role of older patients' goals in GP decision-making about medicines: a qualitative study. BMC FAMILY PRACTICE 2021; 22:13. [PMID: 33419389 PMCID: PMC7796626 DOI: 10.1186/s12875-020-01347-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To optimise medication use in older people, it is recommended that clinicians evaluate evidence on potential benefits and harms of medicines in light of the patients' overall health, values and goals. This suggests general practitioners (GPs) should attempt to facilitate patient involvement in decision-making. In practice this is often challenging. In this qualitative study, we explored GPs' perspectives on the importance of discussing patients' goals and preferences, and the role patient preferences play in medicines management and prioritisation. METHODS Semi-structured interviews were conducted with GPs from Australia (n = 32). Participants were purposively sampled to recruit GPs with variation in experience level and geographic location. Transcribed audio-recordings of interviews were coded using Framework Analysis. RESULTS The results showed that most GPs recognised some value in understanding older patients' goals and preferences regarding their medicines. Most reported some discussions of goals and preferences with patients, but often this was initiated by the patient. Practical barriers were reported such as limited time during busy consultations to discuss issues beyond acute problems. GPs differed on the following main themes: 1) definition and perception of patients' goals, 2) relationship with the patient, 3) approach to medicines management and prioritisation. We observed that GPs preferred one of three different practice patterns in their approach to patients' goals in medicines decisions: 1) goals and preferences considered lower priority - 'Directive'; 2) goals seen as central - 'Goal-oriented'; 3) goals and preferences considered but not explicitly elicited - 'Tacit'. CONCLUSIONS This study explores how GPs differ in their approach to eliciting patients' goals and preferences, and how these differences are operationalised in the context of older adults taking multiple medicines. Although there are challenges in providing care that aligns with patients' goals and preferences, this study shows how complex decisions are made between GPs and their older patients in clinical practice. This work may inform future research that investigates how GPs can best incorporate the priorities of older people in decision-making around medicines. Developing practical support strategies may assist clinicians to involve patients in discussions about their medicines.
Collapse
Affiliation(s)
- Kristie Rebecca Weir
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia.
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Ageing and Alzheimer's Institute, Concord Repatriation General Hospital, Concord West, New South Wales, 2139, Australia
| | - Stacy M Carter
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, Faculty of the Arts, Humanities and Social Sciences, University of Wollongong, Keiraville, New South Wales, 2522, Australia
| | - Chun Wah Michael Tam
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, New South Wales, 2170, Australia
- School of Population Health, The University of New South Wales, Sydney, New South Wales, 2052, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Carissa Bonner
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Debbie Rigby
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane City, Queensland, 4000, Australia
| | - Andrew J McLachlan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Jesse Jansen
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia
| |
Collapse
|
16
|
Lefebvre MJ, Ng PCK, Desjarlais A, McCann D, Waldvogel B, Tonelli M, Garg AX, Wilson JA, Beaulieu M, Marin J, Orsulak C, Lloyd A, McIntyre C, Feldberg J, Bohm C, Battistella M. Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy. Can J Kidney Health Dis 2020; 7:2054358120968674. [PMID: 33194213 PMCID: PMC7605037 DOI: 10.1177/2054358120968674] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/14/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor. Objective: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD. Design: Questionnaires and materials sent electronically. Participants: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists). Methods: A literature search was performed to develop the initial algorithms via Lynn’s method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn’s method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved. Results: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as “Agree” or “Strongly Agree” ranged from 84% to 95% (average of all five questions, across three rounds). Limitations: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools. Conclusions: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.
Collapse
Affiliation(s)
| | - Patrick C K Ng
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | | | - Dennis McCann
- Patient Partners, Can-SOLVE CKD Network, Vancouver, BC, Canada
| | - Blair Waldvogel
- Patient Partners, Can-SOLVE CKD Network, Vancouver, BC, Canada
| | | | - Amit X Garg
- Institute for Clinical Evaluative Sciences, London, ON, Canada.,Division of Nephrology, Department of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Jo-Anne Wilson
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Canada.,Faculty of Health, College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Monica Beaulieu
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | | | | | | | - Caitlin McIntyre
- Department of Pharmacy, University Health Network, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Jordanne Feldberg
- Department of Pharmacy, University Health Network, Toronto, ON, Canada.,Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Clara Bohm
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Marisa Battistella
- Department of Pharmacy, University Health Network, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| |
Collapse
|
17
|
Mangin D, Garfinkel D. Foreword to the first special collection: Addressing the invisible iatrogenic epidemic: the role of deprescribing in polypharmacy and inappropriate medication use. Ther Adv Drug Saf 2019; 10:2042098619883156. [PMID: 31673327 PMCID: PMC6804352 DOI: 10.1177/2042098619883156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Doron Garfinkel
- Geriatric-Palliative consultant, Sheba Medical Center and Homecare Hospice, Israel Cancer Association, Israel
| |
Collapse
|
18
|
Al-Aly Z, Maddukuri G, Xie Y. Proton Pump Inhibitors and the Kidney: Implications of Current Evidence for Clinical Practice and When and How to Deprescribe. Am J Kidney Dis 2019; 75:497-507. [PMID: 31606235 DOI: 10.1053/j.ajkd.2019.07.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
Proton pump inhibitors (PPIs), long thought to be safe, are associated with a number of nonkidney adverse health outcomes and several untoward kidney outcomes, including hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, kidney failure, and increased risk for all-cause mortality and mortality due to chronic kidney disease. PPIs are abundantly prescribed, rarely deprescribed, and frequently purchased over the counter. They are frequently used without medical indication, and when medically indicated, they are often used for much longer than needed. In this In Practice review, we summarize evidence linking PPI use with adverse events in general and adverse kidney outcomes in particular. We review the literature on the association of PPI use and risk for hypomagnesemia, acute kidney injury, acute interstitial nephritis, incident chronic kidney disease, kidney disease progression, end-stage kidney disease, and death. We provide an assessment of how this evidence should inform clinical practice. We review the impact of this evidence on patients' perception of risk, synthesize PPI deprescription literature, and provide our recommendations on how to approach PPI use and deprescription.
Collapse
Affiliation(s)
- Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO.
| | - Geetha Maddukuri
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of St. Louis, Saint Louis, MO
| |
Collapse
|
19
|
Jung SY, Lee HJ. Utilisation of medications among elderly patients in intensive care units: a cross-sectional study using a nationwide claims database. BMJ Open 2019; 9:e026605. [PMID: 31340958 PMCID: PMC6661704 DOI: 10.1136/bmjopen-2018-026605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Clinical practice guidelines for the management of pain and sedation in critically ill patients have been developed and applied; however, there is limited data on medication use among elderly patients. This study identifies current practice patterns for analgo-sedative use in mechanically ventilated elderly patients in Korea using a national claims database. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS Ventilated elderly patients aged 65 years or older in intensive care units (ICUs) from an aged patients' national claims database in Korea PRIMARY OUTCOME MEASURES: Use of sedatives including benzodiazepines, opioids and non-opioid analgesics, neuromuscular blocking agents (NMBAs) and antipsychotic drugs were analysed by the duration of mechanical ventilation (MV), age and time. RESULTS From 2012 to 2016, 22 677 elderly patients underwent MV in 267 general or tertiary ICUs. Mean age was 77.2 (±6.9) years and the median duration of MV was 4.1 days; 77.2% of patients received sedatives, 65.0% analgesics, 29.1% NMBAs and 19.6% antipsychotics. Midazolam (62.0%) was the most commonly prescribed medication. The proportions of sedatives, analgesics and NMBAs increased, whereas the percentages of person-days decreased with longer MV duration (p<0.01). With advanced age, the prevalence and duration of sedative, analgesic and NMBA use decreased (adjusted OR (95% CI) 0.98 (0.97 to 0.98) in all three classes) while antipsychotic did not (adjusted OR 1.00 (1.00-1.01)). Annually, benzodiazepines showed reduced administration (76.2% in 2012 and 71.4% in 2016, p<0.01), while daily opioid dose increased (21.6 in 2012 vs 30.0 mg in 2016, p<0.01). CONCLUSIONS The prevalence of sedative, analgesic and NMBAs use and daily opioid doses were lower, whereas antipsychotic use was higher compared with those in previous studies in adult patients. The findings warrant further studies investigating appropriateness and safety of medication use that consider clinical severity scores with a focus on elderly patients in ICUs.
Collapse
Affiliation(s)
- Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Hyun Joo Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
20
|
Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Simmons SF. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Serv Res 2019; 19:165. [PMID: 30871561 PMCID: PMC6416929 DOI: 10.1186/s12913-019-3995-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
Collapse
Affiliation(s)
- Eduard E. Vasilevskis
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Avantika S. Shah
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
| | | | | | - Amanda S. Mixon
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - John F. Schnelle
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| |
Collapse
|
21
|
Weir KR, Bonner C, McCaffery K, Naganathan V, Carter SM, Rigby D, Trevena L, McLachlan A, Jansen J. Pharmacists and patients sharing decisions about medicines: Development and feasibility of a conversation guide. Res Social Adm Pharm 2018; 15:682-690. [PMID: 30172642 DOI: 10.1016/j.sapharm.2018.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In Australia, the Home Medicines Review (HMR) is a nationally-funded program, led by pharmacists to optimize medication use for older people. A Medicines Conversation Guide was developed for pharmacists to use in the context of a HMR. The Guide aims to increase patient involvement and support discussions about: general health understanding, decision-making and information preferences, health priorities related to medicines, patient goals and fears, views on important activities and trade-offs. OBJECTIVE This study describes the development and feasibility testing of a Medicines Conversation Guide in HMRs with pharmacists and older patients. METHODS The Guide was developed using a systematic and iterative process, followed by testing in clinical practice with 11 pharmacists, 17 patients (aged 65+) and their companions. A researcher observed HMRs, surveyed and qualitatively interviewed patients and pharmacists to discuss feasibility. Transcribed recordings of the interviews were thematically coded and a Framework Analysis method used. RESULTS Pharmacists found the Guide to be an acceptable and useful component to the HMR, especially among patients with limited knowledge of their medicines. The Guide seemed most effective when integrated with the HMR and tailored to suit the individual patient. Some questions were difficult for patients to grasp (e.g. trade-offs) or sounded formal. Most patients found the Guide focused the HMR on their perspective and encouraged a more holistic approach to the HMR. From the quantitative survey, pharmacists found the Guide easy to implement, balanced and understandable. CONCLUSIONS Pharmacists and patients reported the Guide fits with the HMR encounter relatively easily and promoted communication about goals and preferences in relation to medications. This study highlighted some key challenges for communication about medicines and how the Guide may help support the process of involving patients more in the HMR.
Collapse
Affiliation(s)
- Kristie Rebecca Weir
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia
| | - Carissa Bonner
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, The University of Sydney, NSW, 2006, Australia; Ageing and Alzheimer's Institute, Concord Repatriation General Hospital, NSW, 2139, Australia
| | - Stacy M Carter
- Research for Social Change, Faculty of Social Science, The University of Wollongong, NSW, 2522, Australia
| | - Debbie Rigby
- DR Pharmacy Consulting, Brisbane, QLD, Australia
| | - Lyndal Trevena
- Ask Share Know Centre for Research Excellence, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia
| | - Andrew McLachlan
- Centre for Education and Research on Ageing (CERA), Concord Clinical School, The University of Sydney, NSW, 2006, Australia; Faculty of Pharmacy, University of Sydney, NSW, 2006, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, NSW, 2006, Australia.
| |
Collapse
|