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McCarthy JM, Chaplin E. Adults with Intellectual Disability and Autism Spectrum Disorder: What Is the Evidence around the Use of Polypharmacy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15974. [PMID: 36498043 PMCID: PMC9738258 DOI: 10.3390/ijerph192315974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
A review on the mental health needs of adults with intellectual disability (ID) and autism spectrum disorder (ASD) published just over 10 years ago found a limited evidence base for pharmacological intervention in this group. The aim of this paper was therefore to review the evidence in the subsequent 10 years, with a focus on polypharmacy use in adults who have both ID and ASD. A critical literature review of key papers published from 2009 to 2021 was undertaken on adults with both ID and ASD and related to psychopharmacology, polypharmacy, antipsychotics, antidepressants, mood stabilisers and anxiolytics interventions in improving symptoms. After excluding articles for lack of relevance, a review with a focus on the use of polypharmacy was carried out on the retrieved results. Four papers were identified as relevant to adults with both ID and ASD. Three main themes were identified in the review, including the application of pharmacogenetics, the influence of national policy on prescribing practices and safety concerns in a population with multiple health comorbidities. The past decade has produced a small increase in the evidence base on psychopharmacology use in adults with ID and ASD. However, more evidence on the effectiveness and impact of long-term polypharmacy use is required.
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Affiliation(s)
- Jane M. McCarthy
- Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK
| | - Eddie Chaplin
- Foundation for People with Learning Disabilities, Institute of Health and Social Care, London South Bank University, London SE1 0AA, UK
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Durbin A, Balogh R, Lin E, Palma L, Plumptre L, Lunsky Y. Changes in community and hospital-based health care use during the COVID-19 pandemic for adults with and without intellectual and developmental disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2022; 66:399-412. [PMID: 35353400 PMCID: PMC9115061 DOI: 10.1111/jir.12929] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Due to the functional, cognitive and communication impairments associated with intellectual and/or developmental disabilities (IDD), adaptations to service delivery during the COVID-19 pandemic may impact people with IDD differently than others. For community and hospital-based services, this study describes the proportion of adults with and without IDD who used health care in the year pre-COVID-19 and the first year of the pandemic. METHODS This retrospective cohort study used linked health administrative databases to identify adults aged 18-105 years with and without IDD using unique encoded identifiers. Counts and proportions of adults who used health care services were reported for the pre-COVID-19 year (16 March 2019 to 14 March 2020) and the first COVID-19 year (15 March 2020 to 15 March 2021). RESULTS Across services, the proportion of adults who used services was lower during the first COVID-19 year compared with the year prior, except for virtual physician visits that increased markedly for people with and without IDD. While the proportion of adults who used services was higher for those with IDD compared with those without IDD for both years, differences were greatest for mental health emergency visits and hospitalisations; adults with IDD were 6.3 to 10.9 times more likely to use these services than others with no IDD during the pandemic. CONCLUSIONS During the first COVID-19 year in Ontario, Canada, service use decreased for all service types, except for virtual physician visits. In both years, adults with IDD remained more likely to use services than other adults, with the largest differences in use of mental health hospitalisations and mental health emergency department visits.
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Affiliation(s)
- A. Durbin
- Unity Health Toronto, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
- ICESTorontoOntarioCanada
- Department of Psychiatry, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - R. Balogh
- ICESTorontoOntarioCanada
- Faculty of Health SciencesOntario Tech University Unity HealthOshawaOntarioCanada
| | - E. Lin
- ICESTorontoOntarioCanada
- Department of Psychiatry, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - L. Palma
- Department of Psychiatry, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - L. Plumptre
- Department of Psychiatry, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Y. Lunsky
- Unity Health Toronto, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
- ICESTorontoOntarioCanada
- Department of Psychiatry, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Azrieli Adult Neurodevelopmental CentreCentre for Addiction and Mental Health (CAMH)TorontoOntarioCanada
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Psychotropic Medication Monitoring in a Human Services Organization for Children with Autism Spectrum Disorder: Description and Evaluation of Interdisciplinary Team Review. Behav Anal Pract 2022; 15:1337-1347. [PMID: 35371414 PMCID: PMC8956327 DOI: 10.1007/s40617-022-00699-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/15/2022] Open
Abstract
Children with autism spectrum disorder (ASD) are often prescribed psychotropic medications but pharmacotherapy is typically conducted and evaluated based on clinical judgement without reference to objective measurement of treatment effectiveness and combined efficacy of pharmacological-behavioral interventions. We describe an interdisciplinary review team (IRT) model at a human services organization for children with ASD that was designed to standardize a process of psychotropic medication monitoring through (1) coordinated involvement of medical, nursing, behavior analyst, and special education professionals, (2) parent-guardian participation, (3) data-driven decision making, and (4) high-level administrative support. Our description includes case illustrations of medication reduction-elimination trials with five students and social validity assessment of IRT clinicians, nurses, and parent-guardians. Key components of the IRT model are emphasized with associated practice and research recommendations.
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Yoshida K, Koyama E, Zai CC, Beitchman JH, Kennedy JL, Lunsky Y, Desarkar P, Müller DJ. Pharmacogenomic Studies in Intellectual Disabilities and Autism Spectrum Disorder: A Systematic Review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:1019-1041. [PMID: 33222504 PMCID: PMC8689451 DOI: 10.1177/0706743720971950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Individuals with intellectual disability (ID) and autism spectrum disorder (ASD) often receive psychotropic medications such as antipsychotics and antidepressants to treat aberrant behaviors and mood symptoms, frequently resulting in polypharmacy and drug-related adverse effects. Pharmacogenomic (PGx) studies with ASD and/or ID (ASD/ID) have been scarce despite the promise of optimizing treatment outcomes. We reviewed the literature on PGx studies with antipsychotics and antidepressants (e.g., treatment response and adverse effects) in ASD/ID. METHODS We performed a systematic review using MEDLINE, Embase, and PsycINFO, including peer-reviewed original articles in English referring to PGx in the treatment of ASD/ID in any age groups (e.g., treatment response and adverse effects). RESULTS A total of 28 PGx studies using mostly candidate gene approaches were identified across age groups. Notably, only 3 studies included adults with ASD/ID while the other 25 studies focused specifically on children/adolescents with ASD/ID. Twelve studies primarily investigated treatment response, of which 5 and 6 studies included patients treated with antipsychotics and antidepressants, respectively. Most interesting results for response were reported for 2 sets of candidate gene studies, namely: (1) The DRD3 Ser9Gly (rs6280) polymorphism was examined in patients treated with risperidone in 3 studies, 2 of which reported an association with risperidone treatment response and (2) the SLC6A4 5-HTTLPR polymorphism and treatment response to antidepressants which was investigated in 4 studies, 3 of which reported significant associations. In regard to side effects, 9 of 15 studies focused on hyperprolactinemia in patients treated with risperidone. Among them, 7 and 5 studies examined the impact of CYP2D6 and DRD2 Taq1A polymorphisms, respectively, yielding mostly negative study findings. CONCLUSIONS There is limited data available on PGx in individuals with ASD/ID and in particular in adults. Given the potential for PGx testing in improving treatment outcomes, additional PGx studies for psychotropic treatment in ASD/ID across age groups are warranted.
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Affiliation(s)
- Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Emiko Koyama
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Clement C Zai
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Joseph H Beitchman
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada
| | - James L Kennedy
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Yona Lunsky
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Pushpal Desarkar
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada.,Adult Neurodevelopmental Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
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Whitney DG, Schmidt M, Haapala H. Polypharmacy is a risk factor for mortality, severe chronic kidney disease, and liver disease among privately insured adults with cerebral palsy. J Manag Care Spec Pharm 2021; 27:51-63. [PMID: 33377441 PMCID: PMC10391225 DOI: 10.18553/jmcp.2021.27.1.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Adults with cerebral palsy (CP) have an increased risk for polypharmacy, premature mortality, and early development of several morbidities, including conditions associated with excess medication exposure, such as chronic kidney disease (CKD) and liver disease. To date, very little is known about the consequence of polypharmacy for adults with CP. OBJECTIVE: To determine if polypharmacy is associated with an increased risk for mortality, severe CKD, and liver disease among adults with CP, before and after adjusting for comorbid neurodevelopmental disabilities (NDDs) and multimorbidity. METHODS: This is an exploratory treatment effectiveness study. Data from the Optum Clinformatics Data Mart were used for this retrospective cohort study. Adults aged 18 years or older with a diagnosis of CP and without severe CKD (stages IV+) and liver disease were identified from the calendar year 2013 and were subsequently followed from January 1, 2014, to death, severe CKD, liver disease, loss to follow-up, or end of study period (December 31, 2017). Diagnosis codes were used to identify NDDs (intellectual disabilities, epilepsy, autism spectrum disorders, spina bifida) and 24 relevant morbidities at baseline (i.e., calendar year 2013). Polypharmacy was defined as ≥ 5 medications and hyperpolypharmacy was defined as ≥ 10 medications at baseline. Cox regression models were developed to examine the association (as HR and 95% CI) between polypharmacy and hyperpolypharmacy with mortality, severe CKD, and liver disease separately, before and after adjusting for covariates (demographics, NDDs, multimorbidity). Exploratory analyses examined the mediating effect of incident severe CKD or liver disease on the association between the exposure (polypharmacy or hyperpolypharmacy) on outcomes. RESULTS: Of the 9,238 adults with CP, 58.5% had polypharmacy and 29.5% had hyperpolypharmacy. The fully adjusted HR for mortality was 2.14 (95% CI = 1.59-2.89) for polypharmacy and 1.65 (95% CI = 1.31-2.09) for hyperpolypharmacy. The fully adjusted HR for severe CKD was 1.66 (95% CI = 1.17-2.36) for polypharmacy and 1.67 (95% CI = 1.27-2.19) for hyperpolypharmacy. The fully adjusted HR for liver disease was 1.57 (95% CI = 1.27-1.94) for polypharmacy and 1.72 (95% CI = 1.42-2.08) for hyperpolypharmacy. Incident liver disease mediated 5.37% (polypharmacy) and 7.54% (hyperpolypharmacy) of the association between the exposure with incident severe CKD for nonelderly (aged < 65 years), while incident severe CKD mediated 7.05% (polypharmacy) and 6.64% (hyperpolypharmacy) of the association between the exposure with incident liver disease for elderly (aged ≥ 65 years). CONCLUSIONS: Polypharmacy and hyperpolypharmacy are robust risk factors for risk of mortality, severe CKD, and liver disease among privately insured adults with CP. While incidence of severe CKD and liver disease had negligible effects on the association between polypharmacy with mortality, there is evidence that they mediate a considerable portion of one another and require further examination. DISCLOSURES: During the work for this study, Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and American Academy for Cerebral Palsy and Developmental Medicine. The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The authors have no conflicts of interest to report.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mary Schmidt
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
| | - Heidi Haapala
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
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Whitney DG, Schmidt M, Peterson MD, Haapala H. Polypharmacy Among Privately Insured Adults with Cerebral Palsy: A Retrospective Cohort Study. J Manag Care Spec Pharm 2020; 26:1153-1161. [PMID: 32857655 PMCID: PMC10391110 DOI: 10.18553/jmcp.2020.26.9.1153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adults with cerebral palsy (CP) have increased risk for developing various secondary chronic diseases, especially when they have other neurodevelopmental disabilities (NDDs). Multiple medications are likely prescribed to manage the greater morbidity-related burden for adults with CP; however, because health care delivery and care coordination is suboptimal for this population, adults with CP may have an increased risk for polypharmacy. To date, very little is known about the prescribing practices and extent of polypharmacy for adults with CP. OBJECTIVE To determine the prevalence and adjusted odds of polypharmacy among adults with CP only and those with CP+NDDs, compared with adults without CP. METHODS Data from 2017 Optum Clinformatics Data Mart, a U.S. private administrative database, was used for this retrospective cohort study. Diagnosis codes were used to identify adults (aged ≥ 18 years) with CP, NDDs (e.g., intellectual disabilities, epilepsy, and autism spectrum disorders), and 24 relevant morbidities. Polypharmacy was examined as 0-4 versus ≥ 5, 0-9 versus ≥ 10, and 0-14 versus ≥ 15 medications. Logistic regression estimated the OR and 95% CI of polypharmacy before and after adjusting for age, sex, region of residence, and multimorbidity (as 0, 1, 2, 3, 4-5, and ≥ 6 morbidities). Exploratory analyses were conducted to compare polypharmacy among young (18-40 years) and middle-aged (41-64 years) adults with CP only and CP + NDDs with elderly (≥ 65 years) adults without CP. RESULTS Adults with CP only (n = 5,603) and CP + NDDs (n = 2,474) had higher unadjusted prevalence and adjusted OR for each polypharmacy definition compared with adults without CP (n = 9.0 million; e.g., ≥ 5 medications: adjusted OR for CP only = 1.38, 95% CI = 1.30-1.47; CP + NDDs: OR = 2.42, 95% CI = 2.20-2.67). Adults with CP+NDDs had higher unadjusted prevalence and adjusted OR of each polypharmacy definition compared with CP only. Compared with elderly without CP, the unadjusted prevalence of polypharmacy was lower for young adults with CP only (e.g., ≥ 5 medications: 60.2%, 43.8%), similar for young adults with CP+NDDs (e.g., ≥ 15 medications: 10.9%, 12.5%), and elevated for middle-aged CP only and CP + NDDs (e.g., ≥ 10 medications: 28.7%, 34.3%, 41.7%). CONCLUSIONS Privately insured adults with CP only and CP + NDDs have an elevated prevalence of polypharmacy compared with adults without CP, even after accounting for multimorbidity. Importantly, adults aged 18-40 years with CP have a similar (CP + NDDs) prevalence of polypharmacy compared with the general geriatric population, with the prevalence increasing further for CP by middle age. DISCLOSURES Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and the American Academy of Cerebral Palsy and Developmental Medicine. These funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The other authors have no conflicts of interest to disclose.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mary Schmidt
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
| | - Mark D. Peterson
- Department of Physical Medicine and Rehabilitation and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Heidi Haapala
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
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O’Dwyer M, McCallion P, McCarron M, O’Connell J, Henman M. Measuring drug burden in older adults with intellectual disabilities: Critical issues for consideration in finding the optimal measure to improve safety of medicines use. Expert Opin Drug Saf 2020; 19:649-652. [DOI: 10.1080/14740338.2020.1751119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Maire O’Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
| | | | - Mary McCarron
- Trinity Centre for Ageing and Intellectual Disability, School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
| | - Juliette O’Connell
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
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Abstract
Many adults with autism spectrum disorders (ASDs) are admitted as an inpatient, and much has been reported on their ASD-related characteristics and aggressive behaviors that complicate their care during hospitalizations. A variety of surgical and medical clinical conditions have required their admissions in the critical care unit. A limited number of case studies are present for hospitalized adults with ASD; most literature about young children was on how to provide care for them. An interdisciplinary approach with a focus on determining information specific to adult patients with ASD, medical problems or common causes of challenging behaviors, and medication history, as well as nutritional needs, is essential in meeting the care needs of autistic adults. Suggestions informed by multiple sources of evidence are presented to assist critical care nurses on how to provide support to care needs of adult patients with ASD during their hospital stay and transition to home.
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Psychotropic Medication in Intellectual and Developmental Disabilities: Patterns of Use and Recommendations for Monitoring Effects. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2019. [DOI: 10.1007/s40474-019-00179-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Nabhanizadeh A, Oppewal A, Boot FH, Maes-Festen D. Effectiveness of medication reviews in identifying and reducing medication-related problems among people with intellectual disabilities: A systematic review. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2019; 32:750-761. [PMID: 30793852 PMCID: PMC6850346 DOI: 10.1111/jar.12580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 12/21/2018] [Accepted: 01/30/2019] [Indexed: 01/11/2023]
Abstract
Background Polypharmacy is common in people with intellectual disabilities. Using multiple medication may lead to unintended medication‐related problems (MRPs). Medication review may serve as a tool to reduce MRPs. This systematic review assessed the scientific evidence for the effectiveness of medication reviews in identifying and reducing MRPs in people with intellectual disabilities. Method Literature databases were searched up to August 2017. Studies were selected that included the effect of medication reviews on identifying and/or reducing MRPs in people with intellectual disabilities with no restriction of type of medication, age and level of intellectual disabilities. Results The eight studies that fulfilled the inclusion criteria report that systematic medication reviews appear to assist in the identification and reduction of MRPs. Conclusion There is a lack of studies about the effect of medication reviews on identification and reduction of MRPs, especially health outcomes for people with intellectual disabilities. Further studies with long‐term follow‐up are needed.
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Affiliation(s)
- Amal Nabhanizadeh
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Alyt Oppewal
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - Dederieke Maes-Festen
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Lunsky Y, De Oliveira C, Wilton A, Wodchis W. High health care costs among adults with intellectual and developmental disabilities: a population-based study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2019; 63:124-137. [PMID: 30381849 DOI: 10.1111/jir.12554] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 05/08/2023]
Abstract
OBJECTIVE While it is generally accepted that adults with intellectual and developmental disabilities (IDDs) use health services to a greater extent than the general population, there is remarkably little research that focuses on the costs associated with their health care. Using population-based data from adults with IDD in Ontario, this study aimed to estimate overall health care costs, classify individuals into high and non-high cost categories and describe differences in the demographics, clinical profiles and health care use patterns between these groups. DESIGN A retrospective cohort study based in Ontario, Canada, was conducted with the use of linked administrative health data. METHODS A costing algorithm developed for the general population in Ontario was applied to estimate health care costs of adults with IDD under age 65 for 2009 and 2010. Individuals were categorised into two groups according to whether their total annual health care costs were among the highest decile in the general population. These groups were compared on demographic and clinical variables, and relative mean costs for six types of health care services in the two groups were computed. In addition, we computed the proportion of individuals who remained in the high cost group over 2 years. RESULTS Among adults with IDD, 36% had annual health care expenditures greater than $2610 CAD (top decile of all Ontario adults under 65). These individuals were more likely to be female, to be in the oldest age groups, to live in group homes and to be receiving disability income support than individuals whose expenditures were below the high cost threshold. In addition, they had higher rates of all the physical and mental health conditions studied. Greatest health care expenses were due to hospitalisations, especially psychiatric hospitalisations, continuing care/rehabilitation costs and medication costs. The majority of individuals whose health care costs placed them in the high cost category in 2009 remained in that category a year later. DISCUSSION Adults with IDD are nearly 4 times as likely to incur high annual health care costs than those without IDD. Individuals with IDD and high health care costs have unique health and demographic profiles compared with adults with IDD whose annual health care costs are below the high cost threshold. Attending to their health care needs earlier in their health care trajectory may be an opportunity to improve health and reduce overall health care costs. It is important that we explore how to best meet their needs. Models proposed to meet the needs of adults with high health care costs in the general population may not apply to this unique group.
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Affiliation(s)
- Y Lunsky
- Azrieli Centre for Adult Neurodevelopmental Disabilities and Mental Health, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - C De Oliveira
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - W Wodchis
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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O’Dwyer M, McCallion P, McCarron M, Henman M. Medication use and potentially inappropriate prescribing in older adults with intellectual disabilities: a neglected area of research. Ther Adv Drug Saf 2018; 9:535-557. [PMID: 30181861 PMCID: PMC6116771 DOI: 10.1177/2042098618782785] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/23/2018] [Indexed: 01/19/2023] Open
Abstract
It is known that for all adults, prevalence of potentially inappropriate prescribing (PIP) and polypharmacy increases with advancing age and morbidity. This has been associated with adverse drug reactions and poor outcomes. As a result, screening tools have been developed to identify PIP and to improve prescribing and health outcomes. A growing body of evidence supports the fact that there are even greater concerns among older adults with intellectual disability (ID) who are living longer than before but still have premature mortality and poorer health outcomes compared with the general population. They have different patterns of multimorbidity, with higher rates of epilepsy and mental health conditions. Polypharmacy is prevalent and some prescribing practices may be inappropriate. High exposure to anticholinergic and sedative medicines has additional adverse effects on quality of life. There may also be underutilization of clinically needed therapies. There has been substantial controversy internationally relating to extensive use of psychotropic medicines, particularly off-label use for challenging behaviours. Despite the mounting evidence and concerns about the impact of PIP on quality of life, health and safety for people with ID, appropriate methods to measure PIP are lacking, which represents an important gap in the research literature. Differences in morbidity and medicines use patterns in this population mean instruments used to identify inappropriate medicines in the older population are not suitable. In this perspective article we outline the specific health and medicinal needs for people with ID, the prevalence of polypharmacy and presentation of chronic health conditions in older adults with ID. We provide an overview of the psychotropic medicine classes most frequently used in people with ID which carry substantial risk. We highlight studies to date that have attempted to assess PIP and present research priorities to improve prescribing, health outcomes and quality of life for people with ID.
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Affiliation(s)
- Maire O’Dwyer
- School of Pharmacy and Pharmaceutical Sciences,
University of Dublin Trinity College, Trinity College Dublin, Dublin,
Ireland
| | - Philip McCallion
- School of Social Work, College of Public Health,
Temple University, Philadelphia, PA, USA
| | - Mary McCarron
- Faculty of Health Sciences, University of Dublin
Trinity College, Dublin, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences,
University of Dublin Trinity College, Dublin, Ireland
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Fujiura GT, Li H, Magaña S. Health Services Use and Costs for Americans With Intellectual and Developmental Disabilities: A National Analysis. INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2018; 56:101-118. [PMID: 29584559 DOI: 10.1352/1934-9556-56.2.101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Health services and associated costs for adults with intellectual and developmental disabilities (IDD) were nationally profiled and the predictors of high expense users statistically modeled. Using linked data from the National Health Interview Survey and Medical Expenditure Panel Survey for the years 2002 through 2011, the study found a mixed pattern of differences in rates of service use and costs when compared to the general population depending upon personal characteristics, health status, and type of health care service. Prescription medication costs were the primary driver of total health care expenditures for Americans with IDD. The presence of secondary chronic health conditions and poor mental health status were the consistent predictors of high expense users across types of health care. Study results are discussed in terms of implications for more nuanced evaluations of health care costs and need for recurring surveillance of health care for Americans with IDD in the years following passage of the Patient Protection and Affordable Care Act.
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Affiliation(s)
- Glenn T Fujiura
- Glenn T. Fujiura, University of Illinois, Chicago; Henan Li, Brandeis University, and Sandy Magaña, University of Texas
| | - Henan Li
- Glenn T. Fujiura, University of Illinois, Chicago; Henan Li, Brandeis University, and Sandy Magaña, University of Texas
| | - Sandy Magaña
- Glenn T. Fujiura, University of Illinois, Chicago; Henan Li, Brandeis University, and Sandy Magaña, University of Texas
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Zaal RJ, Ebbers S, Borms M, Koning BD, Mombarg E, Ooms P, Vollaard H, van den Bemt PMLA, Evenhuis HM. Medication review using a Systematic Tool to Reduce Inappropriate Prescribing (STRIP) in adults with an intellectual disability: A pilot study. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 55:132-142. [PMID: 27065309 DOI: 10.1016/j.ridd.2016.03.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 07/15/2015] [Accepted: 03/24/2016] [Indexed: 06/05/2023]
Abstract
A Systematic Tool to Reduce Inappropriate Prescribing (STRIP), which includes the Screening Tool to Alert doctors to Right Treatment (START) and the Screening Tool of Older Peoples' Prescriptions (STOPP), has recently been developed in the Netherlands for older patients with polypharmacy in the general population. Active involvement of the patient is part of this systematic multidisciplinary medication review. Although annual review of pharmacotherapy is recommended for people with an intellectual disability (ID), a specific tool for this population is not yet available. Besides, active involvement can be compromised by ID. Therefore, the objective of this observational pilot study was to evaluate the process of medication review using STRIP in adults with an ID living in a centralized or dependent setting and the identification of drug-related problems using this tool. The study was performed in three residential care organizations for ID. In each organization nine clients with polypharmacy were selected by an investigator (a physician in training to become a specialized physician for individuals with an ID) for a review using STRIP. Clients as well as their legal representatives (usually a family member) and professional caregivers were invited to participate. Reviews were performed by an investigator together with a pharmacist. First, to evaluate the process time-investments of the investigator and the pharmacist were described. Besides, the proportion of reviews in which a client and/or his legal representative participated was calculated as well as the proportion of professional caregivers that participated. Second, to evaluate the identification of drug-related problems using STRIP, the proportion of clients with at least one drug-related problem was calculated. Mean time investment was 130minutes for the investigator and 90minutes for the pharmacist. The client and/or a legal representatives were present during 25 of 27 reviews (93%). All 27 professional caregivers (100%) were involved. For every client included at least one drug-related problem was identified. In total 127 drug-related problems were detected, mainly potentially inappropriate or unnecessary drugs. After six months, 15.7% of the interventions were actually implemented. Medication review using STRIP seems feasible in adults with an ID and identifies drug-related problems. However, in this pilot study the implementation rate of suggested interventions was low. To improve the implementation rate, the treating physician should be involved in the review process. Besides, specific adaptations to STRIP to address drug-related problems specific for this population are required.
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Affiliation(s)
- Rianne J Zaal
- Erasmus Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands.
| | | | - Mirka Borms
- Het Raamwerk, Noordwijkerhout, The Netherlands
| | | | | | - Piet Ooms
- De Katwijkse Apotheek, Katwijk, The Netherlands
| | | | | | - Heleen M Evenhuis
- Erasmus Medical Center, Department of General Practice, Intellectual Disability Medicine, Rotterdam, The Netherlands
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Brown HK, Lunsky Y, Wilton AS, Cobigo V, Vigod SN. Pregnancy in Women With Intellectual and Developmental Disabilities. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:9-16. [PMID: 26872750 DOI: 10.1016/j.jogc.2015.10.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Our objectives were to describe the general fertility rate (GFR) and age-specific fertility rates (ASFRs) of women with intellectual and developmental disabilities (IDD) and the social and health characteristics of those with a singleton live birth, and to compare these to women without IDD. METHODS In this population-based retrospective cohort study using linked Ontario health and social services administrative data, we identified 18- to 49-year-old women with IDD (N = 21 181) and without IDD (N = 990 776). The GFR and ASFRs (2009) were calculated for both groups and compared using rate ratios (RR) and 95% confidence intervals (CI). Among women with a singleton live birth (N = 423 with, N = 42 439 without IDD), social and health characteristics were compared using Pearson's Chi square tests. RESULTS The GFR in women with IDD (20.3 per 1000) was lower than that in women without IDD (43.4 per 1000) (RR 0.47; 95% CI 0.43 to 0.51). ASFRs in 18- to 24-year-olds were similar in both groups. Among women with a singleton live birth, those with IDD were younger and had higher rates of poverty, epilepsy, obesity, and mental health issues. They also had high rates of medication use during pregnancy. CONCLUSION In the largest study of fertility in women with IDD to date, we found that ASFRs are similar in young women with and without IDD. Women with IDD with a singleton live birth experience significant social and health disparities during pregnancy. These findings suggest the need to develop services to support the reproductive health of this vulnerable group.
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Affiliation(s)
- Hilary K Brown
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Institute for Clinical Evaluative Sciences, Toronto, Ontario; Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Yona Lunsky
- Institute for Clinical Evaluative Sciences, Toronto, Ontario; Department of Psychiatry, University of Toronto, Toronto, Ontario; Centre for Addiction and Mental Health, Toronto, Ontario
| | - Andrew S Wilton
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Virginie Cobigo
- Institute for Clinical Evaluative Sciences, Toronto, Ontario; School of Psychology, University of Ottawa, Ottawa, Ontario
| | - Simone N Vigod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Institute for Clinical Evaluative Sciences, Toronto, Ontario; Department of Psychiatry, University of Toronto, Toronto, Ontario
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Valdovinos MG, Henninger-McMahon M, Schieber E, Beard L, Conley B, Haas A. Assessing the Impact of Psychotropic Medication Changes on Challenging Behavior of Individuals with Intellectual Disabilities. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2016; 62:200-211. [PMID: 27429750 PMCID: PMC4941788 DOI: 10.1080/20473869.2016.1177301] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The use of psychotropic medication to address challenging behavior in individuals diagnosed with intellectual disabilities is common practice; however, very few studies have examined how multiple medication use (or combination treatment) impacts the behaviors these medications are prescribed to treat. METHOD The current study followed eight individuals over a two-year period as they experienced changes in their psychotropic medication regimens. During that time, data from functional analyses and indirect assessments of challenging behavior were collected. RESULTS The results suggest that changes in psychotropic medication regimens can produce changes in functional assessment outcomes, suggesting a need for continued behavioral assessment to better inform medication practices and behavioral treatment. Of the eight participants in the study, five participants' behaviors varied in rate of responding in FAs across all medication changes. Additionally, three participants' FAs produced changes in outcomes; however, those changes were not consistent across all medication changes, that is, not every medication change yielded different outcomes from previous assessments. CONCLUSION This study demonstrates how the outcome of an FA can be used to monitor the effects of psychotropic medication changes, specifically when medications are combined, on challenging behavior in individuals with intellectual and developmental disabilities.
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O'Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ Open 2016; 6:e010505. [PMID: 27044582 PMCID: PMC4823458 DOI: 10.1136/bmjopen-2015-010505] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/03/2016] [Accepted: 03/07/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES (1) To evaluate the prevalence of polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines) and (2) to determine associated demographic and clinical characteristics in an ageing population with intellectual disabilities (IDs). DESIGN Observational cross-sectional study. SETTING Wave One (2009/2010) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). PARTICIPANTS A nationally representative sample of 753 persons with ID, aged between 41 and 90 years. Participants/proxy reported medicines (prescription and over the counter) taken on a regular basis; medication data was available for 736 participants (98%). MAIN OUTCOME MEASURES/INTERVENTIONS Participants were divided into those with no polypharmacy (0-4 medicines), polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines). Medication use patterns were analysed according to demographic variables and reported chronic conditions. A multinomial logistic regression model identified factors associated with polypharmacy (5-9 medicines) and excessive polypharmacy (≥10 medicines). RESULTS Overall, 90% of participants reported use of medicines. Polypharmacy was observed in 31.5% of participants and excessive polypharmacy in 20.1%. Living in a residential institution, and reporting a mental health or neurological condition were strongly associated with polypharmacy and excessive polypharmacy after adjusting for confounders, but age or gender had no significant effect. CONCLUSIONS Polypharmacy was commonplace for older adults with ID and may be partly explained by the high prevalence of multimorbidity reported. Review of appropriateness of medication use is essential, as polypharmacy places ageing people with ID at risk of adverse effects.
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Affiliation(s)
- Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jure Peklar
- School of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Philip McCallion
- Center for Excellence in Aging and Community Wellness, University At Albany, New York, USA
| | - Mary McCarron
- Dean of the Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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Goldschmidt J, Song HJ. At-risk and underserved: a proposed role for nutrition in the adult trajectory of autism. J Acad Nutr Diet 2015; 115:1041-7. [PMID: 25840938 DOI: 10.1016/j.jand.2015.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 12/14/2022]
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Haider SI, Ansari Z, Vaughan L, Matters H, Emerson E. Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability. RESEARCH IN DEVELOPMENTAL DISABILITIES 2014; 35:3071-3080. [PMID: 25129201 DOI: 10.1016/j.ridd.2014.07.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 06/03/2023]
Abstract
Although polypharmacy is a medication safety concern leading to increased risk of non-adherence, adverse drug reaction and drug-drug interactions, polypharmacy and associated risk factors has rarely been investigated involving people with ID at a population level. The purpose of this paper is to analyze the prevalence of polypharmacy and to evaluate the role of different factors associated with polypharmacy in a state-wide representative population of adults with ID. In a population-based survey in Victoria, Australia, 897 people with ID 18 years of age or older were selected by simple random sampling. The data were collected from proxy respondents on behalf of people with ID. Polypharmacy was defined as the concomitant use of five or more medications. The data were weighted to reflect the age/sex/geographic distribution of the population. Results revealed that more than 76% of adults with ID had used prescribed medicine and about 21% were exposed to polypharmacy in the last two weeks. In both univariate and multivariate analyses, polypharmacy was significantly associated with older age, unemployment and inability to get help from family and friends if needed. After controlling for age, sex and severity of intellectual disability, polypharmacy was associated with having a blood pressure, blood cholesterol and blood glucose level check. Polypharmacy was also associated with a greater number of visits to general practitioners, fair or poor reported health status and inability to walk unaided. Subjects with epilepsy, diabetes, stroke, osteoporosis and cancer had a higher probability of polypharmacy. None of the disease inducing behaviors was associated with polypharmacy. This study highlights the need that medication should be regularly reviewed overall in ID population and particularly when polypharmacy exists.
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Affiliation(s)
- Syed Imran Haider
- Health Intelligence Unit, Victorian Government Department of Health, 50 Lonsdale Street, Melbourne, Victoria 3000, Australia.
| | - Zahid Ansari
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Loretta Vaughan
- Health Intelligence Unit, Victorian Government Department of Health, 50 Lonsdale Street, Melbourne, Victoria 3000, Australia
| | - Helen Matters
- Service Design and Implementation Group, Victorian Government Department of Human Services, 50 Lonsdale Street, Melbourne, Victoria 3000, Australia
| | - Eric Emerson
- Centre for Disability Research & Policy, University of Sydney, Australia
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