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Damiaens A, Van Hecke A, Foulon V. The RESPECT-tool as a facilitator for person-centered medication reviews for nursing home residents: tool development and pilot study. Int J Clin Pharm 2023; 45:1434-1443. [PMID: 37493905 DOI: 10.1007/s11096-023-01621-w] [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: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Although support is needed, no method exists to elicit and integrate personal goals into medication optimization interventions for nursing home residents. AIM To develop and evaluate a tool to (1) elicit and evaluate residents' personal goals during medication optimization, and (2) elicit involvement preferences regarding medication decision-making. METHOD A draft was composed by the research team, on which feedback was collected through four focus groups with healthcare professionals (n = 23) and pilot interviews with residents (n = 6). The tool was then pilot tested in 11 nursing homes as means to facilitate person-centered medication reviews, focusing on feasibility, appropriateness, and meaningfulness. Evaluation was performed through interviews and focus groups with residents and healthcare professionals, and reports for executed medication reviews. Interview summaries and reports were analyzed inductively. RESULTS The RESident's Participation in the Evaluation and Customization of Therapy tool (RESPECT-tool) was drafted as a modular approach of five modules. Pilot study results showed that the tool supported the formulation of personal goals. Goals resulted in changes in all aspects of the nursing home stay, indicating the tool's potential to promote person-centered care. The RESPECT-tool showed value in the context of medication optimization as it allowed to determine potential links between residents' personal goals and medication plans, and its use regularly led to medication changes. CONCLUSION A person-centered medication review facilitated by the RESPECT-tool holds a promising approach to medication optimization in nursing homes. Further research should assess impact on relevant outcomes like goal attainment, appropriateness of prescribing and quality of life.
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Affiliation(s)
- Amber Damiaens
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, O&N II, Box 521, 3000, Leuven, Belgium.
| | - Ann Van Hecke
- Department of Nursing Director, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, O&N II, Box 521, 3000, Leuven, Belgium
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Michael HU, Enechukwu O, Brouillette MJ, Tamblyn R, Fellows LK, Mayo NE. The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis. Drugs Aging 2023; 40:763-783. [PMID: 37462902 DOI: 10.1007/s40266-023-01050-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies. METHOD A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data. RESULTS Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness. CONCLUSIONS Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.
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Affiliation(s)
- Henry Ukachukwu Michael
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada.
| | | | - Marie-Josée Brouillette
- Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada
- Chronic Viral Illness Service, McGill University Health Centre (MUHC), Montreal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, MUHC-RI, Montreal, QC, Canada
| | - Robyn Tamblyn
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Lesley K Fellows
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Nancy E Mayo
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
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Jamieson H, Nishtala P, Bergler HU, Weaver S, Pickering J, Ailabouni N, Abey-Nesbit R, Gullery C, Deely J, Gee S, Hilmer S, Mangin D. Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2023; 78:1692-1700. [PMID: 36692224 PMCID: PMC10460556 DOI: 10.1093/gerona/glac249] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners. METHODS Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months. RESULTS Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level. CONCLUSION Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.
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Affiliation(s)
- Hamish Jamieson
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, Centre for Therapeutic Innovation, University of Bath, Bath, UK
| | - Hans Ulrich Bergler
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Susan K Weaver
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Nagham J Ailabouni
- The Pharmacy Australian Centre of Excellence (PACE), School of Pharmacy, University of Queensland, Brisbane, Queensland, South Australia, Australia
- UniSA Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Rebecca Abey-Nesbit
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Carolyn Gullery
- Planning, Funding and Decision Support, Canterbury District Health Board, General Manager of Planning, Funding and Decision Support; Lightfoot Solutions, Healthcare Systems, Specialist Advisor, Berkshire, UK
| | - Joanne Deely
- Burwood Academy Trust, Christchurch, New Zealand
| | - Susan B Gee
- Psychiatry of Old Age Academic Unit, Canterbury District Health Board, Christchurch, New Zealand
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Dee Mangin
- Primary Care Research Group, University of Otago, Christchurch, New Zealand
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Lee K, Kouladjian O'Donnell L, Cross AJ, Hawthorne D, Page AT. Clinical pharmacists' reported approaches and processes for undertaking Home Medicines Review services: A national survey. Arch Gerontol Geriatr 2023; 109:104965. [PMID: 36821873 DOI: 10.1016/j.archger.2023.104965] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Comprehensive medicines reviews are a strategy to reduce medicines-related harm. In Australia, Home Medicines Review services (HMRs) are provided by consultant pharmacists to community-dwelling consumers, on referral from the consumer's medical practitioner. Limited research exists on the processes undertaken by consultant pharmacists when delivering HMRs, particularly as it relates to the information types received, collected, and reported. OBJECTIVE Describe the types of information consultant pharmacists report receiving in HMR referrals, collect before and during consumer consultations, and include in their written reports. MATERIALS AND METHODS We conducted a national online survey of Australian consultant pharmacists who deliver HMRs. Participants were recruited using a broad advertising strategy, including social and traditional media platforms, and snowballing. Data were analysed descriptively. RESULTS Of the 248 eligible participants, 179 (72%) completed the survey. The most commonly included information in the referral was medication list (97%), the least were details of hospitalisations (8%) and specialist letters (5%). Information pertaining to hospitalisation and specialist letters were collected by 20% of participants prior to the consultation. Details of, and history from, community pharmacy was the most sought information prior to consultations. Less than a quarter of participants 'most of the time' or 'always' formally assess adherence using a validated instrument during the consultation. Participants commonly (80%) report consumer concerns in the written report. CONCLUSIONS Consultant pharmacists collect a broad variety of information, beyond medicines-related content. Written HMR reports by consultant pharmacists were often reported to be consumer-centric.
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Affiliation(s)
- Kenneth Lee
- Centre for Optimisation of Medicines, Discipline of Pharmacy, School of Allied Health, University of Western Australia, Perth, Australia.
| | - Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Sydney, Australia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Science, Monash University, Parkville, Australia
| | - Deborah Hawthorne
- Centre for Optimisation of Medicines, Discipline of Pharmacy, School of Allied Health, University of Western Australia, Perth, Australia; Western Australian Centre for Health & Ageing, School of Allied Health, University of Western Australia, Perth, Australia
| | - Amy Theresa Page
- Centre for Optimisation of Medicines, Discipline of Pharmacy, School of Allied Health, University of Western Australia, Perth, Australia; Western Australian Centre for Health & Ageing, School of Allied Health, University of Western Australia, Perth, Australia
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Damiaens A, Maes E, Van Roosbroek H, Van Hecke A, Foulon V. Methods to elicit and evaluate the attainment of patient goals in older adults: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:3051-3061. [PMID: 35691792 DOI: 10.1016/j.pec.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This scoping review aimed to identify patient goal elicitation and evaluation methods for older adults, and to investigate which methods can be used in medication optimization interventions for nursing home residents (NHRs). METHODS The Arksey and O'Malley framework guided the review. A search was launched in PubMed, Embase, CINAHL, and Web of Science. Reference selection and data extraction were performed by three independent reviewers, followed by team discussions to solve discrepancies. Inductive thematic analysis was applied to synthesize the data. Included papers were reconsidered to identify methods for medication optimization interventions for NHRs. RESULTS Ninety-six references, encompassing 38 elicitation and 12 evaluation methods, were included. Elicitation methods differed in structure, content, and patient involvement levels. Qualitative and quantitative methods were found to assess goal attainment. Five elicitation and three evaluation methods were developed for NHRs, but none of these contained a medication-related assessment. CONCLUSION A variety of goal elicitation and evaluation methods for older adults was found, but none for medication optimization interventions in NHRs. PRACTICE IMPLICATIONS A holistic approach seems important to integrate patient goals into medication optimization interventions, not limiting goal elicitation to a medication-related assessment. Also, the choice of assessor seems important to obtain patient goals.
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Affiliation(s)
- Amber Damiaens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Evelien Maes
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hanne Van Roosbroek
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Ann Van Hecke
- Department of Public Health and Primary Care, UGent, Department of Nursing Director, Ghent University Hospital Ghent, Belgium.
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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Bergler U, Ailabouni NJ, Pickering JW, Hilmer SN, Mangin D, Nishtala PS, Jamieson H. Deprescribing to reduce polypharmacy: study protocol for a randomised controlled trial assessing deprescribing of anticholinergic and sedative drugs in a cohort of frail older people living in the community. Trials 2021; 22:766. [PMID: 34732234 PMCID: PMC8564597 DOI: 10.1186/s13063-021-05711-w] [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: 03/31/2021] [Accepted: 10/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community. METHODS AND ANALYSIS The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients. STUDY POPULATION Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly. INTERVENTION New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI). OUTCOMES The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death. DATA COLLECTION POINTS Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3). ETHICS AND DISSEMINATION Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265). TRIAL REGISTRATION ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry.
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Affiliation(s)
- Ulrich Bergler
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Nagham J Ailabouni
- UniSA Clinical & Health Sciences, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, Australia
| | - Dee Mangin
- Department of Medicine, University of Otago, Christchurch, New Zealand.,David Braley and Nancy Gordon Chair in Family Medicine, McMaster University, Hamilton, Canada
| | | | - Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand. .,Burwood Hospital, Canterbury District Health Board, Christchurch, New Zealand.
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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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Junius-Walker U, Viniol A, Michiels-Corsten M, Gerlach N, Donner-Banzhoff N, Schleef T. MediQuit, an Electronic Deprescribing Tool for Patients on Polypharmacy: Results of a Feasibility Study in German General Practice. Drugs Aging 2021; 38:725-733. [PMID: 34251594 PMCID: PMC8342343 DOI: 10.1007/s40266-021-00861-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Deprescribing is an important task for general practitioners (GPs) in the face of risky polypharmacy. The electronic tool "MediQuit" was developed to guide GPs and patients through a deprescribing consultation that entails a drug-selection phase, shared decision making, and advice on safe implementation. OBJECTIVES A pilot study was conducted to determine the target group of patients that is selected for consultation and to assess the impact, patient involvement, and feasibility of the tool. METHODS This was an uncontrolled pilot study. GPs from two German regions were invited to use MediQuit in consultations with a view to deprescribing one drug, if appropriate. They selected patients on the basis of broad inclusion criteria. Collected data entailed participants' characteristics, patients' medication lists, deprescribed drugs, and feasibility assessments. Patients were contacted shortly after the consultation and again after 4 weeks. RESULTS In total, 16 GPs agreed to participate, of whom ten actually performed deprescribing consultations. They selected 41 predominately older patients on excessive polypharmacy. Deprescribing was achieved in 70% of consultations in agreement with patients. Drugs deprescribed were symptom-lowering and preventive drugs (mainly anatomical therapeutic chemical classes A and C). GPs found MediQuit useful in initiating communication on this issue and enhancing deliberations for a deprescribing decision. The median consultation length was 15 min (interquartile range 10-20). At follow-up, GPs and patients infrequently disagreed on which drug(s) was discontinued, and GPs rated patient involvement higher than did patients themselves. DISCUSSION MediQuit assists in identifying concrete deprescribing opportunities, patient involvement, and shared decision making. The three-step deprescribing procedure is well-accepted once initial organizational efforts are overcome. After revision, further studies are needed to enhance the quality of evidence on acceptance and effectiveness.
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Affiliation(s)
| | - Annika Viniol
- Institute of General Practice, Marburg University, Marburg, Germany
| | | | - Navina Gerlach
- Institute of General Practice, Marburg University, Marburg, Germany
| | | | - Tanja Schleef
- Institute of General Practice, Hannover Medical School, Hannover, Germany
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9
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Ailabouni NJ, Reeve E, Helfrich CD, Hilmer SN, Wagenaar BH. Leveraging implementation science to increase the translation of deprescribing evidence into practice. Res Social Adm Pharm 2021; 18:2550-2555. [PMID: 34147372 DOI: 10.1016/j.sapharm.2021.05.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings.
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Affiliation(s)
- Nagham J Ailabouni
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia.
| | - Emily Reeve
- University of South Australia, UniSA: Clinical and Health Sciences, Quality Use of Medicines and Pharmacy Research Centre (QUMPRC), Adelaide, SA, Australia; Dalhousie University and Nova Scotia Health Authority, Geriatric Medicine Research, Faculty of Medicine, And College of Pharmacy Halifax, Canada
| | - Christian D Helfrich
- University of Washington, School of Public Health, Veterans Administration Puget Sound Health Care System, Seattle, WA, USA
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
| | - Bradley H Wagenaar
- University of Washington, Department of Global Health, Seattle, WA, USA; University of Washington, Department of Epidemiology, Seattle, WA, USA
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11
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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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12
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The utility of a computerised clinical decision support system intervention in home medicines review: A mixed-methods process evaluation. Res Social Adm Pharm 2021; 17:715-722. [DOI: 10.1016/j.sapharm.2020.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/21/2022]
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13
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Rockwood K, Andrew MK, Aubertin‐Leheudre M, Belleville S, Bherer L, Bowles SK, Kehler DS, Lim A, Middleton L, Phillips N, Wallace LM. CCCDTD5: Reducing the risk of later-life dementia. Evidence informing the Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5). ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12083. [PMID: 33204818 PMCID: PMC7656906 DOI: 10.1002/trc2.12083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 11/23/2022]
Abstract
The Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5) was a year-long process to synthesize the best available evidence on several topics. Our group undertook evaluation of risk reduction, in eight domains: nutrition; physical activity; hearing; sleep; cognitive training and stimulation; social engagement and education; frailty; and medications. Here we describe the rationale for the undertaking and summarize the background evidence-this is also tabulated in the Appendix. We further comment specifically on the relationship between age and dementia, and offer some suggestions for how reducing the risk of dementia in the seventh decade and beyond might be considered if we are to improve prospects for prevention in the near term. We draw to attention that a well-specified model of success in dementia prevention need not equate to the elimination of cognitive impairment in late life.
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Affiliation(s)
- Kenneth Rockwood
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Melissa K. Andrew
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | | | - Sylvie Belleville
- Research CenterInstitut Universitaire de Gériatrie de MontréalMontréalQuebecCanada
- Psychology DepartmentUniversité de MontréalMontréalCanada
| | - Louis Bherer
- Département de Médecine, Faculté de médecine, Université de Montréal, Centre de recherche, Institut de cardiologie de Montréal, Centre de rechercheInstitut universitaire de gériatrie de MontréalMontréalQuébecCanada
| | - Susan K. Bowles
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
- College of PharmacyDalhousie UniversityHalifaxNova ScotiaCanada
| | - D Scott Kehler
- School of PhysiotherapyDalhousie UniversityHalifaxNova ScotiaCanada
| | - Andrew Lim
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Laura Middleton
- Department of KinesiologyUniversity of WaterlooWaterlooOntarioCanada
| | - Natalie Phillips
- Department of PsychologyConcordia UniversityMontréalQuébecCanada
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14
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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: 27] [Impact Index Per Article: 6.8] [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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15
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O'Donnell LK, Sawan M, Reeve E, Gnjidic D, Chen TF, Kelly PJ, Bell JS, Hilmer SN. Correction to: Implementation of the goal-directed medication review electronic decision support system (G-MEDSS)© into home medicines review: a protocol for a clusterrandomised clinical trial in older adults. BMC Geriatr 2020; 20:378. [PMID: 33008288 PMCID: PMC7532095 DOI: 10.1186/s12877-020-01681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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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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