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Onor IO, Ahmed F, Nguyen AN, Ezebuenyi MC, Obi CU, Schafer AK, Borghol A, Aguilar E, Okogbaa JI, Reisin E. Polypharmacy in chronic kidney disease: Health outcomes & pharmacy-based strategies to mitigate inappropriate polypharmacy. Am J Med Sci 2024; 367:4-13. [PMID: 37832917 DOI: 10.1016/j.amjms.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023]
Abstract
The rising prevalence of comorbidities in an increasingly aging population has sparked a reciprocal rise in polypharmacy. Patients with chronic kidney disease (CKD) have a greater burden of polypharmacy due to the comorbidities and complications associated with their disease. Polypharmacy in CKD patients has been linked to myriad direct and indirect costs for patients and the society at large. Pharmacists are uniquely positioned within the healthcare team to streamline polypharmacy management in the setting of CKD. In this article, we review the landscape of polypharmacy and examine its impacts through the lens of the ECHO model of Economic, Clinical, and Humanistic Outcomes. We also present strategies for healthcare teams to improve polypharmacy care through comprehensive medication management process that includes medication reconciliation during transitions of care, medication therapy management, and deprescribing. These pharmacist-led interventions have the potential to mitigate adverse outcomes associated with polypharmacy in CKD.
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Affiliation(s)
- IfeanyiChukwu O Onor
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA; Department of Pharmacy, University Medical Center New Orleans, New Orleans, LA, USA.
| | - Fahamina Ahmed
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; East Jefferson General Hospital-Family Medicine Clinic, Metairie, LA, USA
| | - Anthony N Nguyen
- Department of Pharmacy, Ochsner Health System, Jefferson, LA, USA
| | - Michael C Ezebuenyi
- Department of Pharmacy, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
| | - Collins Uchechukwu Obi
- Medical Laboratory Science Department, Nnamdi Azikiwe University, Nnewi Campus, Anambra, Nigeria
| | - Alison K Schafer
- Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Amne Borghol
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA; Department of Pharmacy, University Medical Center New Orleans, New Orleans, LA, USA
| | - Erwin Aguilar
- Department of Medicine, Section of Nephrology and Hypertension, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - John I Okogbaa
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA, USA; Department of Medicine, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Efrain Reisin
- Department of Medicine, Section of Nephrology and Hypertension, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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Baretella O, Alwan H, Feller M, Aubert CE, Del Giovane C, Papazoglou D, Christiaens A, Meinders AJ, Byrne S, Kearney PM, O'Mahony D, Knol W, Boland B, Gencer B, Aujesky D, Rodondi N. Overtreatment and associated risk factors among multimorbid older patients with diabetes. J Am Geriatr Soc 2023; 71:2893-2901. [PMID: 37286338 DOI: 10.1111/jgs.18465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose-lowering medication (GLM) should be focused on attaining a suitable level of glycated hemoglobin (HbA1c ) while avoiding side effects. We aimed at identifying patients with overtreatment of T2DM as well as associated risk factors. METHODS In a secondary analysis of a multicenter study of multimorbid older patients, we evaluated HbA1c levels among patients with T2DM. Patients were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses) and polypharmacy (≥5 chronic medications), enrolled in four university medical centers across Europe (Belgium, Ireland, Netherlands, and Switzerland). We defined overtreatment as HbA1c < 7.5% with ≥1 GLM other than metformin, as suggested by Choosing Wisely and used prevalence ratios (PRs) to evaluate risk factors of overtreatment in age- and sex-adjusted analyses. RESULTS Among the 564 patients with T2DM (median age 78 years, 39% women), mean ± standard deviation HbA1c was 7.2 ± 1.2%. Metformin (prevalence 51%) was the most frequently prescribed GLM and 199 (35%) patients were overtreated. The presence of severe renal impairment (PR 1.36, 1.21-1.53) and outpatient physician (other than general practitioner [GP], i.e. specialist) or emergency department visits (PR 1.22, 1.03-1.46 for 1-2 visits, and PR 1.35, 1.19-1.54 for ≥3 visits versus no visits) were associated with overtreatment. These factors remained associated with overtreatment in multivariable analyses. CONCLUSIONS In this multicountry study of multimorbid older patients with T2DM, more than one third were overtreated, highlighting the high prevalence of this problem. Careful balancing of benefits and risks in the choice of GLM may improve patient care, especially in the context of comorbidities such as severe renal impairment, and frequent non-GP healthcare contacts.
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Affiliation(s)
- Oliver Baretella
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Heba Alwan
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carole E Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Dimitrios Papazoglou
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Antoine Christiaens
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, INSERM, Paris, France
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Arend-Jan Meinders
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Stephen Byrne
- School of Pharmacy, University College Cork - National University of Ireland, Cork, Republic of Ireland
| | - Patricia M Kearney
- School of Public Health, University College Cork, Cork, Republic of Ireland
- Department of Medicine Cork, University College Cork - National University of Ireland, Cork, Republic of Ireland
| | - Denis O'Mahony
- Department of Medicine Cork, University College Cork - National University of Ireland, Cork, Republic of Ireland
- Department of Geriatric Medicine Cork, Cork University Hospital Group, Cork, Republic of Ireland
| | - Wilma Knol
- Department of Geriatrics and Expertise Centre Pharmacotherapy in Old Persons (EPHOR), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Benoît Boland
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
- Department of Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Service de cardiologie, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Goh SSL, Lai PSM, Ramdzan SN, Tan KM. Weighing the necessities and concerns of deprescribing among older ambulatory patients and primary care trainees: a qualitative study. BMC PRIMARY CARE 2023; 24:136. [PMID: 37391698 PMCID: PMC10311750 DOI: 10.1186/s12875-023-02084-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 06/19/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Deprescribing can be a challenging and complex process, particularly for early career doctors such as primary care trainees. To date, there is limited data from patients' and doctors' perspectives regarding the deprescribing of medications in older persons, particularly from developing countries. This study aimed to explore the necessities and concerns of deprescribing in older persons among older ambulatory patients and primary care trainees. METHODS A qualitative study was conducted among patients and primary care trainees (known henceforth as doctors). Patients aged ≥ 60 years, having ≥ 1 chronic disease and prescribed ≥ 5 medications and could communicate in either English or Malay were recruited. Doctors and patients were purposively sampled based on their stage of training as family medicine specialists and ethnicity, respectively. All interviews were audio-recorded and transcribed verbatim. A thematic approach was used to analyse data. RESULTS Twenty-four in-depth interviews (IDIs) with patients and four focus group discussions (FGDs) with 23 doctors were conducted. Four themes emerged: understanding the concept of deprescribing, the necessity to perform deprescribing, concerns regarding deprescribing and factors influencing deprescribing. Patients were receptive to the idea of deprescribing when the term was explained to them, whilst doctors had a good understanding of deprescribing. Both patients and doctors would deprescribe when the necessity outweighed their concerns. Factors that influenced deprescribing were doctor-patient rapport, health literacy among patients, external influences from carers and social media, and system challenges. CONCLUSION Deprescribing was deemed necessary by both patients and doctors when there was a reason to do so. However, both doctors and patients were afraid to deprescribe as they 'didn't want to rock the boat'. Early-career doctors were reluctant to deprescribe as they felt compelled to continue medications that were initiated by another specialist. Doctors requested more training on how to deprescribe medications.
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Affiliation(s)
- Sheron Sir Loon Goh
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
- School of Medical and Life Sciences, Sunway University, Sunway City, Selangor, 47500, Malaysia.
| | - Siti Nurkamilla Ramdzan
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kit Mun Tan
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
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El-Dahiyat F, Jairoun AA, Al-Hemyari SS, Shahwan M, Hassan N, Jairoun S, Jaber AAS. Are pharmacists' knowledge and practice the key to promoting deprescribing of potentially inappropriate medication: a missing link between treatment and outcomes. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7146786. [PMID: 37116892 DOI: 10.1093/ijpp/riad027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 04/13/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Deprescribing is a novel strategy whereby medical professionals aim to optimize a patient's prescription program by removing redundant medications. Few studies have looked at the viewpoints of community pharmacists and other healthcare professionals on deprescribing in daily practice. This study's objectives included evaluating community pharmacists' deprescribing knowledge, attitudes and practices, as well as identifying the obstacles to and enablers of deprescribing in daily practice. METHODS Five pharmacy students in the last year of their studies polled employees of neighbourhood pharmacies in Abu Dhabi, Dubai, and the Northern Emirates from April 2022 to July 2022. The study's questionnaire was divided into two sections: questions that inquired about the respondents' demographic data and questions that evaluated the respondents' understanding and usage of the deprescribing of potentially harmful medications for patients. The original Bloom's cutoff points were revised and modified to assess the general knowledge and deprescribing practices of United Arab Emirates (UAE) community pharmacists. Multivariate logistic regression identified the variables influencing respondents' deprescribing knowledge and practice. KEY FINDINGS The average age of the participants was 30.8 ± 6.4 SD. Of the total, 255 (37.7%) were male and 422 (62.3%) were female. Pharmacists from independent pharmacies constituted 52.9% of the study sample and 47.1% were from Chain pharmacies. Among the participants, 58.8% (n = 398) had 1-5 years of experience and 41.2% (n = 279) had more than 5 years. Nearly three-quarters of the pharmacists (72.1%, 488) graduated from local universities and 27.9% (n = 189) graduated from regional/international universities. The vast majority of the study sample (84.8%, 574) were bachelor's degree holders and 88.3% (n = 598) were pharmacists in charge. Of the total, 69.3% (n = 469) received deprescribing training to treat patients with multimorbid diseases. The knowledge and practice score was 71.3% with a 95% confidence interval [70.2%, 72.4%]. Of the total participants, 113 (16.7%) had poor knowledge and practice about deprescribing, 393 (58.1%) had moderate knowledge and practice and 171 (25.3%) had good knowledge and practice. CONCLUSION This study highlights the level of understanding of community pharmacists about deprescribing in the UAE. Although most of the respondents in this study received training on deprescribing, less than half of the community pharmacists were unaware of certain classes (long-acting sulfonylureas, anti-diabetic, antihyperlipidemic and psychotropic drugs) of drugs that are candidates for potential deprescribing. This finding indicates that their knowledge about deprescribing was insufficient. Several barriers community pharmacists face in deprescribing were also identified, with patients' resistance and insufficience being the most prevalent. Therefore, there is a need for improved deprescribing practices to ensure drug safety.
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Affiliation(s)
- Faris El-Dahiyat
- Clinical Pharmacy Program, College of Pharmacy, Al Ain University, Al Ain, UAE
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, UAE
| | - Ammar Abdulrahman Jairoun
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor, Malaysia
- Health and Safety Department, Dubai Municipality, Dubai, UAE
| | - Sabaa Saleh Al-Hemyari
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor, Malaysia
- Pharmacy Department, Emirates Health Services, Dubai, UAE
| | - Moyad Shahwan
- College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, UAE
| | - Nageeb Hassan
- College of Pharmacy and Health Sciences, Ajman University, Ajman, UAE
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, UAE
| | - Sumaya Jairoun
- Pharmacy Department, Valiant Hospital, Dubai, UAE
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, Al mizhar Dubai, UAE
| | - Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, Al mizhar Dubai, UAE
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Oyedeji CI, Hodulik KL, Telen MJ, Strouse JJ. Management of Older Adults with Sickle Cell Disease: Considerations for Current and Emerging Therapies. Drugs Aging 2023; 40:317-334. [PMID: 36853587 PMCID: PMC10979738 DOI: 10.1007/s40266-023-01014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 03/01/2023]
Abstract
People with sickle cell disease (SCD) are living longer than ever before, with the median survival increasing from age 14 years in 1973, beyond age 40 years in the 1990s, and as high as 61 years in recent cohorts from academic centers. Improvements in survival have been attributed to initiatives, such as newborn screening, penicillin prophylaxis, vaccination against encapsulated organisms, better detection and treatment of splenic sequestration, and improved transfusion support. There are an estimated 100,000 people living with SCD in the United States and millions of people with SCD globally. Given that the number of older adults with SCD will likely continue to increase as survival improves, better evidence on how to manage this population is needed. When managing older adults with SCD (defined herein as age ≥ 40 years), healthcare providers should consider the potential pitfalls of extrapolating evidence from existing studies on current and emerging therapies that have typically been conducted with participants at mean ages far below 40 years. Older adults with SCD have historically had little to no representation in clinical trials; therefore, more guidance is needed on how to use current and emerging therapies in this population. This article summarizes the available evidence for managing older adults with SCD and discusses potential challenges to using approved and emerging drugs in this population.
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Affiliation(s)
- Charity I Oyedeji
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Claude D. Pepper Older Americans Independence Center, Durham, NC, USA.
- Department of Medicine, and Duke Comprehensive Sickle Cell Center, Duke University School of Medicine, 315 Trent Dr., Suite 266, DUMC Box 3939, Durham, NC, 27710, USA.
| | - Kimberly L Hodulik
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John J Strouse
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Claude D. Pepper Older Americans Independence Center, Durham, NC, USA
- Department of Medicine, and Duke Comprehensive Sickle Cell Center, Duke University School of Medicine, 315 Trent Dr., Suite 266, DUMC Box 3939, Durham, NC, 27710, USA
- Division of Pediatric Hematology-Oncology, Duke University, Durham, NC, USA
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Association between Polypharmacy and Cardiovascular Autonomic Function among Elderly Patients in an Urban Municipality Area of Kolkata, India: A Record-Based Cross-Sectional Study. Geriatrics (Basel) 2022; 7:geriatrics7060136. [PMID: 36547272 PMCID: PMC9778147 DOI: 10.3390/geriatrics7060136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
We assessed the association between polypharmacy and cardiovascular autonomic function among community-dwelling elderly patients having chronic diseases. Three hundred and twenty-one patients from an urban municipality area of Kolkata, India were studied in August 2022. The anticholinergic burden and cardiac autonomic function (Valsalva ratio, orthostatic hypotension, change in diastolic blood pressure after an isometric exercise, and heart rate variability during expiration and inspiration) were evaluated. Binary logistic regression analysis was performed to find out the association of polypharmacy and total anticholinergic burden with cardiac autonomic neuropathy. A total of 305 patients (age, 68.9 ± 3.4; 65.9% male) were included. Of these patients, 81 (26.6%) were on polypharmacy. Out of these 81 patients, 42 patients were on ninety-eight potential inappropriate medications. The anticholinergic burden and the proportion of patients with cardiac autonomic neuropathy were significantly higher among patients who were on polypharmacy than those who were not (8.1 ± 2.3 vs. 2.3 ± 0.9; p = 0.03 and 56.8% vs. 44.6%; p = 0.01). The presence of polypharmacy and a total anticholinergic burden of > 3 was significantly associated with cardiac autonomic neuropathy (aOR, 2.66; 95% CI, 0.91−3.98 and aOR, 2.51; 95% CI, 0.99−3.52, respectively). Thus, polypharmacy was significantly associated with cardiac autonomic neuropathy among community-dwelling elderly patients.
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Rothbauer K, Siodlak M, Dreischmeier E, Ranola TS, Welch L. Evaluation of a Pharmacist-Driven Ambulatory Aspirin Deprescribing Protocol. Fed Pract 2022; 39:S37-S41a. [PMID: 36923549 PMCID: PMC10010494 DOI: 10.12788/fp.0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Recent guidelines indicate that aspirin affords less cardiovascular protection and greater bleeding risks in adults aged > 70 years. Deprescribing potentially inappropriate medications is particularly important in older adults, as this population experiences a high risk of adverse effects and polypharmacy. Limited data are available regarding targeted aspirin deprescribing approaches by pharmacists. The objective of this study was to implement and evaluate the success and feasibility of a pharmacist-led aspirin deprescribing protocol for older adults in a primary care setting. Observations This prospective feasibility study in a US Department of Veterans Affairs ambulatory care pharmacy setting included patients aged ≥ 70 years with documented aspirin use. We reviewed 459 patient records and determined that 110 were eligible for deprescribing. A pharmacistinitiated telephone call was attempted for each eligible patient to discuss the risks and benefits of deprescribing aspirin. The primary outcome was the proportion of patients reached for whom aspirin was discontinued. Secondary outcomes included patient rationale for declining deprescribing and the time to complete the intervention. Of 94 patients reached, 45 (48%) agreed to aspirin deprescribing, 3 (3%) agreed to dose reduction, and 29 (31%) declined the intervention. An additional 17 (18%) had previously stopped aspirin, which led to a medication reconciliation intervention. Pharmacists spent about 2 minutes per record review and 12 minutes on each encounter, including documentation. Conclusions Implementing a pharmacist-driven aspirin deprescribing protocol in a primary care setting led to the discontinuation of inappropriate aspirin prescribing in nearly half of older adults contacted. The protocol was well accepted by collaborating physicians and feasible for pharmacists to implement, with potential for further dissemination across primary care settings.
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Affiliation(s)
| | | | | | - Trisha Seys Ranola
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,University of Wisconsin, Madison School of Pharmacy
| | - Lauren Welch
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Desai M, Park T. Deprescribing practices in Canada: A scoping review. Can Pharm J (Ott) 2022; 155:249-257. [PMID: 36081917 PMCID: PMC9445505 DOI: 10.1177/17151635221114114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Background Excessive and inappropriate use of medications, defined as polypharmacy, can increase the risk of adverse drug reactions while affecting patient adherence and quality of life. Therefore, optimizing pharmacotherapies through deprescribing practices plays a crucial role in managing chronic conditions, avoiding adverse effects and improving patient outcomes. The purpose of this study was to explore research initiatives surrounding deprescribing in Canada. Methods A scoping review was conducted that involved a search of 6 databases. Studies that highlighted deprescribing interventions, experiences and other effects on Canadian populations were included. Results Searches yielded 2327 citations, of which 31 were included in this review. Five major themes and ideas were identified: deprescribing targeted medications, financial effects of deprescribing, deprescribing in special populations, insight from health care providers and deprescribing frameworks. Conclusion Deprescribing practices in Canada have shown a wide range of beneficial results across various health care settings, populations and medication classes and have the potential to reduce medication-related harm in all Canadian health care settings.
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Keller MS, Vordenberg SE, Steinman MA. Moving Deprescribing Upstream. J Gen Intern Med 2022; 37:3176-3177. [PMID: 35411528 PMCID: PMC9485366 DOI: 10.1007/s11606-022-07537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/29/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Michelle S. Keller
- Cedars-Sinai Medical Center, Division of General Internal Medicine-Health Services Research, 8687 Melrose Ave, Green Building, Office G-562, Los Angeles, CA 90048 USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA
| | - Sarah E. Vordenberg
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI USA
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, CA USA
- San Francisco VA Medical Center, San Francisco, CA USA
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Hshieh TT, DuMontier C, Jaung T, Bahl NE, Hawley CE, Mozessohn L, Stone RM, Soiffer RJ, Driver JA, Abel GA. Association of Polypharmacy and Potentially Inappropriate Medications With Frailty Among Older Adults With Blood Cancers. J Natl Compr Canc Netw 2022; 20:915-923.e5. [PMID: 35948031 PMCID: PMC10106100 DOI: 10.6004/jnccn.2022.7033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Polypharmacy and potentially inappropriate medications (PIMs) are common among older adults with blood cancers, but their association with frailty and how to manage them optimally remain unclear. PATIENTS AND METHODS From 2015 to 2019, patients aged ≥75 years presenting for initial oncology consult underwent screening geriatric assessment. Patients were determined to be robust, prefrail, or frail via deficit accumulation and phenotypic approaches. We quantified each patient's total number of medications and PIMs using the Anticholinergic Risk Scale (ARS) and a scale we generated using the NCCN Medications of Concern called the Geriatric Oncology Potentially Inappropriate Medications (GO-PIM) scale. We assessed cross-sectional associations of PIMs with frailty in multivariable regression models adjusting for age, gender, and comorbidity. RESULTS Of 785 patients assessed, 603 (77%) were taking ≥5 medications and 421 (54%) were taking ≥8 medications; 201 (25%) were taking at least 1 PIM based on the ARS and 343 (44%) at least 1 PIM based on the GO-PIM scale. Among the 468 (60%) patients on active cancer treatment, taking ≥8 medications was associated with frailty (adjusted odds ratio [aOR], 2.82; 95% CI, 1.92-4.17). With each additional medication, the odds of being prefrail or frail increased 8% (aOR, 1.08; 95% CI, 1.04-1.12). With each 1-point increase on the ARS, the odds of being prefrail or frail increased 19% (aOR, 1.19; 95% CI, 1.03-1.39); with each additional PIM based on the GO-PIM scale, the odds increased 65% (aOR, 1.65; 95% CI, 1.34-2.04). CONCLUSIONS Polypharmacy and PIMs are prevalent among older patients with blood cancers; taking ≥8 medications is strongly associated with frailty. These data suggest careful medication reconciliation for this population may be helpful, and deprescribing when possible is high-yield, especially for PIMs on the GO-PIM scale.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Clark DuMontier
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Timothy Jaung
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Nupur E Bahl
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Chelsea E Hawley
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Lee Mozessohn
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Richard M Stone
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jane A Driver
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A Abel
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Herrmann N, Ismail Z, Collins R, Desmarais P, Goodarzi Z, Henri‐Bhargava A, Iaboni A, Kirkham J, Massoud F, Moser A, Silvius J, Watt J, Seitz D. CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12099. [PMID: 35128025 PMCID: PMC8802736 DOI: 10.1002/trc2.12099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type. METHODS The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers? RESULTS Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized. CONCLUSION CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.
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Affiliation(s)
- Nathan Herrmann
- Department of PsychiatrySunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Cumming School of Medicine; Hotchkiss Brain Institute and O'Brien Institute of Public HealthUniversity of Calgary, Calgary, Alberta, Canada
| | - Rhonda Collins
- Department of Family MedicineMcMaster UniversityChief Medical Officer, Revera IncHamiltonOntarioCanada
| | - Philippe Desmarais
- Department of MedicineDivision of Geriatrics and Department of NeurosciencesCentre de Recherche du Centre Hospitalier de l'Université de MontréalMontréalQuébecCanada
| | - Zahra Goodarzi
- Division of Geriatrics, Department of Medicine, Cumming School of Medicine; Hotchkiss Brain Institute; O'Brien Institute of Public HealthUniversity of CalgaryCalgaryCanada
| | - Alexandre Henri‐Bhargava
- Division of Neurology, Faculty of MedicineUniversity of British Columbia; Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada
| | - Andrea Iaboni
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
- Kite Research Institute, Toronto Rehabilitation InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Julia Kirkham
- Department of PsychiatryCumming School of Medicine, University of Calgary
| | - Fadi Massoud
- Department of MedicineUniversity of SherbrookeSherbrookeQuebecCanada
| | - Andrea Moser
- Department of Family and Community MedicineUniversity of Toronto, Associate Medical Director, Jewish Home for the Aged, BaycrestTorontoOntarioCanada
| | - James Silvius
- Division of Geriatric Medicine, Department of Medicine, Cumming School of MedicineUniversity of Calgary, Calgary, Alberta, Canada
| | - Jennifer Watt
- Division of Geriatric MedicineDepartment of Medicine, University of TorontoTorontoOntarioCanada
| | - Dallas Seitz
- Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Cumming School of Medicine; Hotchkiss Brain Institute and O'Brien Institute of Public HealthUniversity of Calgary, Calgary, Alberta, Canada
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Chappe M, Corvaisier M, Brangier A, Annweiler C, Spiesser-Robelet L. Impact of the COVID-19 pandemic on drug-related problems and pharmacist interventions in geriatric acute care units. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 80:669-677. [PMID: 34968479 PMCID: PMC8711174 DOI: 10.1016/j.pharma.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022]
Abstract
Objectives To assess and compare the pharmaceutical analysis on drug management in a geriatric acute care unit prior to and during the COVID-19 pandemic. Methods This was a single-centre, retrospective, and comparative cohort study. All Pharmacist Interventions (PIs) carried out in the unit between 27 January 2020 and 30 April 2020 were distinguished according to whether they were conducted prior to or during the first wave of COVID-19. The main outcome measure was the rate of PIs per patient and per prescription lines analysed. Other data collected were the drug class managed by the PI, the Drug Related Problems (DRP) identified, the nature of the advice given, and the acceptance rate by geriatricians. Results A total of 355 patients were analysed, with PIs generated for 21.7% of the patients prior to COVID-19, and for 53.4% of the patients during the first wave (p < 0.001). Among the 4402 prescription lines analysed, 54 PIs were carried out for prescriptions prior to COVID-19, and 177 during the first wave (p = 0.002). DRPs were mostly related to anti-infectious drugs during the pandemic (20.3%, p = 0.038), and laxatives prior to the pandemic (13.0%, p = 0.023). The clinical impact of the PIs was mainly moderate (43.7%). The acceptance rate was 59.3%. Conclusions A greater amount of DRPs were detected and more therapeutic advice was proposed during the first wave of COVID-19, with a focus on drugs used for the management of COVID-19 rather than geriatric routine treatments. The needs for clinical pharmacists were strengthened during the pandemic.
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Affiliation(s)
- M Chappe
- Department of Pharmacy, Angers University Hospital, Angers, France; Department of Geriatric Medicine, Research Center on Autonomy and Longevity, Angers University Hospital, Angers, France; Department of Pharmacy, Haut Anjou Hospital, Chateau-Gontier, France.
| | - M Corvaisier
- Department of Pharmacy, Angers University Hospital, Angers, France; Department of Geriatric Medicine, Research Center on Autonomy and Longevity, Angers University Hospital, Angers, France; UPRES EA 4638, University of Angers, Angers, France
| | - A Brangier
- Department of Geriatric Medicine, Research Center on Autonomy and Longevity, Angers University Hospital, Angers, France
| | - C Annweiler
- Department of Geriatric Medicine, Research Center on Autonomy and Longevity, Angers University Hospital, Angers, France; UPRES EA 4638, University of Angers, Angers, France; Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, the University of Western Ontario, London, Ontario, Canada
| | - L Spiesser-Robelet
- Department of Pharmacy, Angers University Hospital, Angers, France; Health Education and Practices Laboratory-LEPS (EA 3412), Paris13-Sorbonne Paris Cité University, Bobigny, France
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13
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Tremblay Z, Mumbere D, Laurin D, Sirois C, Furrer D, Poisblaud L, Carmichael PH, Farrell B, Tourigny A, Giguere A, Vedel I, Morais J, Kröger E. Health Impacts and Characteristics of Deprescribing Interventions in Older Adults: Protocol for a Systematic Review and Meta-analysis. JMIR Res Protoc 2021; 10:e25200. [PMID: 34889771 PMCID: PMC8704115 DOI: 10.2196/25200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 08/05/2021] [Accepted: 09/03/2021] [Indexed: 12/05/2022] Open
Abstract
Background Deprescribing, a relatively recent concept, has been proposed as a promising solution to the growing issues of polypharmacy and use of medications of questionable benefit among older adults. However, little is known about the health outcomes of deprescribing interventions. Objective This paper presents the protocol of a study that aims to contribute to the knowledge on deprescribing by addressing two specific objectives: (1) describe the impact of deprescribing in adults ≥60 years on health outcomes or quality of life; and (2) determine the characteristics of effective interventions in deprescribing. Methods Primary studies targeting three concepts (older adults, deprescribing, and health or quality of life outcomes) will be included in the review. The search will be performed using key international databases (MEDLINE, EMBASE, CINAHL, Ageline, PsycInfo), and a special effort will be made to identify gray literature. Two reviewers will independently screen the articles, extract the information, and evaluate the quality of the selected studies. If methodologically feasible, meta-analyses will be performed for groups of intervention studies reporting on deprescribing interventions for similar medications, used for similar or identical indications, and reporting on similar outcomes (eg, benzodiazepines used against insomnia and studies reporting on quality of sleep or quality of life). Alternatively, the results will be presented in bottom-line statements (objective 1) and a matrix outlining effective interventions (objective 2). Results The knowledge synthesis may be limited by the availability of high-quality clinical trials on deprescribing and their outcomes in older adults. Additionally, analyses will likely be affected by studies on the deprescribing of different types of molecules within the same indication (eg, different pharmacological classes and medications to treat hypertension) and different measures of health and quality of life outcomes for the same indication. Nevertheless, we expect the review to identify which deprescribing interventions lead to improved health outcomes among seniors and which of their characteristics contribute to these outcomes. Conclusions This systematic review will contribute to a better understanding of the health outcomes of deprescribing interventions among seniors. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42015020866; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015020866 International Registered Report Identifier (IRRID) PRR1-10.2196/25200
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Affiliation(s)
- Zoë Tremblay
- Faculté de pharmacie, Université Laval, Québec, QC, Canada
| | - David Mumbere
- Faculté de pharmacie, Université Laval, Québec, QC, Canada
| | | | | | - Daniela Furrer
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Lise Poisblaud
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada
| | - Barbara Farrell
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - André Tourigny
- Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Anik Giguere
- Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Isabelle Vedel
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - José Morais
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Edeltraut Kröger
- Faculté de pharmacie, Université Laval, Québec, QC, Canada.,Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada.,Faculty of Medicine, McGill University, Montreal, QC, Canada
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Feasibility & Efficacy of Deprescribing rounds in a Singapore rehabilitative hospital- a randomised controlled trial. BMC Geriatr 2021; 21:584. [PMID: 34674645 PMCID: PMC8529728 DOI: 10.1186/s12877-021-02507-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 09/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background Deprescribing is effective and safe in reducing polypharmacy among the elderly. However, the impact of deprescribing rounds remain unclear in Asian settings. Hence, we conducted this study. Methods An open label randomised controlled trial was conducted on patients of 65 years and above, under rehabilitation or subacute care and with prespecified medications from a Singapore rehabilitation hospital. They were randomised using a computer generated sequence. The intervention consisted of weekly multidisciplinary team-led deprescribing rounds (using five steps of deprescribing) and usual care. The control had only usual care. The primary outcome is the percentage change in total daily dose (TDD) from baseline upon discharge, while the secondary outcomes are the total number of medicine, total daily cost and TDD up to day 28 postdischarge, overall side-effect rates, rounding time and the challenges. Efficacy outcomes were analysed using intention-to-treat while other outcomes were analysed as per protocol. Results 260 patients were randomised and 253 were analysed after excluding dropouts (female: 57.3%; median age: 76 years). Baseline characteristics were largely similar in both groups. The intervention arm (n = 126) experienced a greater reduction of TDD on discharge [Median (IQR): − 19.62% (− 34.38, 0.00%) versus 0.00% (− 12.00, 6.82%); p < 0.001], more constipation (OR: 3.75, 95% CI:1.75–8.06, p < 0.001) and laxative re-prescriptions (OR: 2.82, 95% CI:1.30–6.12, p = 0.009) though death and hospitalisation rates were similar. The median rounding time was 7.09 min per patient and challenges include the inconvenience in assembling the multidisciplinary team. Conclusion Deprescribing rounds can safely reduce TDD of medicine upon discharge compared to usual care in a Singaporean rehabilitation hospital. Trial registration This study is first registered at Clinicaltrials.gov (protocol number: NCT03713112) on 19/10/2018 and the protocol can be accessed on https://www.clinicaltrials.gov. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02507-0.
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15
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Kosjerina V, Carstensen B, Jørgensen ME, Brock B, Christensen HR, Rungby J, Andersen GS. Discontinuation of diabetes medication in the 10 years before death in Denmark: a register-based study. THE LANCET HEALTHY LONGEVITY 2021; 2:e561-e570. [DOI: 10.1016/s2666-7568(21)00170-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
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16
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Aladul MI, Patel B, Chapman SR. Impact of the introduction of falls risk assessment toolkit on falls prevention and psychotropic medicines' utilisation in Walsall: an interrupted time series analysis. BMJ Open 2021; 11:e039649. [PMID: 34373286 PMCID: PMC8354286 DOI: 10.1136/bmjopen-2020-039649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine the impact of the introduction of a falls risk assessment toolkit (FRAT) in a UK medical centre on the number and cost of non-elective admissions for falls and psychotropic medication utilisation. DESIGN Interrupted time series analysis quantifying the number and cost of non-elective admissions for falls and primary care use data for Rushall Medical Centre before and after the implementation of FRAT at July 2017. SETTING Data on the monthly number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service were provided by Walsall Clinical Commissioning Group. Primary care prescribing cost and volume data for Rushall Medical Centre was derived from the Openprescribing.net website for prescriptions dispensed between April 2015 and November 2018. PRIMARY AND SECONDARY OUTCOME MEASURES The number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service, and the volume of utilisation of psychotropic medicines. RESULTS Following the implementation of FRAT at Rushall Medical Centre in July 2017, the number of non-elective admissions for falls decreased at a rate of 0.414 admissions per month (p<0.033, 95% CI -0.796 to -0.032). The utilisation of psychotropic medications (alimemazine, citalopram, escitalopram, fluoxetine, mirtazapine, olanzapine and risperidone) decreased. The expenditure on psychotropic medications prescribed/used at Rushall Medical Centre decreased by at least £986 per month (p<0.001, 95% CI -2067 to -986). CONCLUSIONS The implementation of FRAT at Rushall Medical Centre was associated with a reduction in the number of non-elective admissions for falls. Assessment of these patients together with deprescribing of psychotropic medications resulted in a reduction in the number of non-elective admissions for falls and associated costs.
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Affiliation(s)
- Mohammed Ibrahim Aladul
- Pharmacy College, Department of Clinical Pharmacy, University of Mosul, Mosul, Iraq
- Pharmacy College, Ninevah University, Mosul, Iraq
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Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. LANCET HEALTHY LONGEVITY 2021; 2:e290-e300. [DOI: 10.1016/s2666-7568(21)00054-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 01/27/2023]
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18
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Aharaz A, Rasmussen JH, McNulty HBØ, Cyron A, Fabricius PK, Bengaard AK, Sejberg HRC, Simonsen RRL, Treldal C, Houlind MB. A Collaborative Deprescribing Intervention in a Subacute Medical Outpatient Clinic: A Pilot Randomized Controlled Trial. Metabolites 2021; 11:204. [PMID: 33808080 PMCID: PMC8066016 DOI: 10.3390/metabo11040204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/11/2021] [Accepted: 03/25/2021] [Indexed: 12/03/2022] Open
Abstract
Medication deprescribing is essential to prevent inappropriate medication use in multimorbid patients. However, experience of deprescribing in Danish Subacute Medical Outpatient Clinics (SMOCs) is limited. The objective of our pilot study was to evaluate the feasibility and sustainability of a collaborative deprescribing intervention by a pharmacist and a physician to multimorbid patients in a SMOC. A randomized controlled pilot study was conducted, with phone follow-up at 30 and 365+ days. A senior pharmacist performed a systematic deprescribing intervention using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, the Danish deprescribing list, and patient interviews. A senior physician received the proposed recommendations and decided which should be implemented. The main outcome was the number of patients having ≥1 medication where deprescribing status was sustained 30 days after inclusion. Out of 76 eligible patients, 72 (95%) were included and 67 (93%) completed the study (57% male; mean age 73 years; mean number of 10 prescribed medications). Nineteen patients (56%) in the intervention group and four (12%) in the control group had ≥1 medication where deprescribing status was sustained 30 days after inclusion (p = 0.015). In total, 37 medications were deprescribed in the intervention group and five in the control group. At 365+ days after inclusion, 97% and 100% of the deprescribed medications were sustained in the intervention and control groups, respectively. The three most frequently deprescribed medication groups were analgesics, cardiovascular, and gastrointestinal medications. In conclusion, a collaborative deprescribing intervention for multimorbid patients was feasible and resulted in sustainable deprescribing of medication in a SMOC.
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Affiliation(s)
- Anissa Aharaz
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
- Multidisciplinary Outpatient Clinic (Fællesambulatoriet, subakutte patientforløb), Copenhagen University Hospital—Amager and Hvidovre, 2300 Copenhagen, Denmark; (J.H.R.); (A.C.)
- Department of Clinical Research, Copenhagen University Hospital—Amager and Hvidovre, 2650 Copenhagen, Denmark;
| | - Jens Henning Rasmussen
- Multidisciplinary Outpatient Clinic (Fællesambulatoriet, subakutte patientforløb), Copenhagen University Hospital—Amager and Hvidovre, 2300 Copenhagen, Denmark; (J.H.R.); (A.C.)
- Department of Emergency Medicine, Copenhagen University Hospital—Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark
| | - Helle Bach Ølgaard McNulty
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
| | - Arne Cyron
- Multidisciplinary Outpatient Clinic (Fællesambulatoriet, subakutte patientforløb), Copenhagen University Hospital—Amager and Hvidovre, 2300 Copenhagen, Denmark; (J.H.R.); (A.C.)
| | - Pia Keinicke Fabricius
- Department of Clinical Research, Copenhagen University Hospital—Amager and Hvidovre, 2650 Copenhagen, Denmark;
| | - Anne Kathrine Bengaard
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
- Department of Clinical Research, Copenhagen University Hospital—Amager and Hvidovre, 2650 Copenhagen, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | | | - Rikke Rie Løvig Simonsen
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
| | - Charlotte Treldal
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
- Department of Clinical Research, Copenhagen University Hospital—Amager and Hvidovre, 2650 Copenhagen, Denmark;
| | - Morten Baltzer Houlind
- The Capital Region Pharmacy, 2730 Herlev, Denmark; (H.B.Ø.M.); (A.K.B.); (H.R.C.S.); (R.R.L.S.); (C.T.); (M.B.H.)
- Department of Clinical Research, Copenhagen University Hospital—Amager and Hvidovre, 2650 Copenhagen, Denmark;
- Department of Drug Design and Pharmacology, University of Copenhagen, 2100 Copenhagen, Denmark
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Cardona M, Stehlik P, Fawzy P, Byambasuren O, Anderson J, Clark J, Sun S, Scott I. Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review. Expert Opin Drug Saf 2020; 20:81-91. [PMID: 33213216 DOI: 10.1080/14740338.2021.1853704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life. Areas covered: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events. Expert opinion: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.
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Affiliation(s)
- Magnolia Cardona
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia.,Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Paulina Stehlik
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia.,Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Peter Fawzy
- Evidence-Based Practice Professorial Unit, Gold Coast University Hospital , Southport, QLD, Australia
| | - Oyungerel Byambasuren
- Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Jarrah Anderson
- School of Pharmacy and Pharmacology, Griffith University , Gold Coast, QLD, Australia
| | - Justin Clark
- Institute for Evidence-Based HealthCare, Bond University , Gold Coast, QLD, Australia
| | - Shelley Sun
- Sydney Medical School, The University of New South Wales , Kensington, NSW, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Metro South, QLD Health , Brisbane, QLD, Australia
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20
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Meyer-Junco L. Time to Deprescribe: A Time-Centric Model for Deprescribing at End of Life. J Palliat Med 2020; 24:273-284. [PMID: 33226878 DOI: 10.1089/jpm.2020.0430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In end-of-life care, deprescribing practices may vary considerably from one practitioner to the next, although most published frameworks for evaluating medication appropriateness in advanced illness consider three key principles (1) patient and caregiver goals, (2) remaining life expectancy (LE), and (3) medication time to benefit (TTB). The objective of this article is to provide clinicians with a structured, consistent approach for deprescribing that does not replace clinical judgment or the preferences of patients and their families but enhances it through clinical data. The emphasis will be on the time component of published models, including how to estimate remaining LE and medication TTB. Through case examples of two new hospice admissions, LE and TTB will be estimated and applied to deprescribing decisions. This time-centric approach may satisfy the palliative and hospice clinicians' desire for clear clinical justification for medication discontinuation while at the same time providing a strategy for communicating deprescribing rationale to patients and families.
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Affiliation(s)
- Laura Meyer-Junco
- Hospice, Palliative Care, and Geriatrics, University of Illinois at Chicago (UIC) College of Pharmacy, Rockford, Illinois, USA
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21
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Gill TM, Gahbauer EA, Leo-Summers L, Murphy TE. Trends in Restricting Symptoms at the End of Life from 1998 to 2019: A Cohort Study of Older Persons. J Am Geriatr Soc 2020; 69:450-458. [PMID: 33145752 DOI: 10.1111/jgs.16871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe changes in the occurrence of restricting symptoms at the end of life from 1998 to 2019 and compare these changes according to the condition leading to death. DESIGN Prospective longitudinal study. SETTING Greater New Haven, CT. PARTICIPANTS A total of 665 decedents from a cohort of 754 community-living persons, 70 years or older. MEASUREMENTS The occurrence of 16 restricting symptoms was ascertained during monthly interviews. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed every 18-months. For each restricting symptom, adjusted rates (per 100 person-months) were calculated separately for six multiyear time intervals. RESULTS From 1998 to 2019, rates decreased for five (31.3%) restricting symptoms (difficulty sleeping; chest pain or tightness; shortness of breath; cold or flu symptoms; and nausea, vomiting, or diarrhea), increased for three (18.8%: arm or leg weakness; urinary incontinence; and memory or thinking problem), and changed little for the other eight (50.0%: poor eyesight; anxiety; depression; musculoskeletal pain; fatigue; dizziness or unsteadiness; frequent or painful urination; and swelling in feet or ankles). The decrease in rates was most pronounced for shortness of breath, with a reduction from 15.0 (95% credible interval = 11.7-18.6) in 1998 to 2001 to 8.2 (95% credible interval = 5.9-10.5) in 2014 to 2019, yielding a rate ratio (95% credible interval) of 0.92 (0.86-0.98). When evaluated according to the condition leading to death, the results were similar, with 10 of the 13 statistically significant rate ratios representing decreases in rates over time and only 3 representing increases. CONCLUSION The occurrence of most restricting symptoms at the end of life has been decreasing or stable over the past two decades. These results suggest that end-of-life care has been improving, although additional efforts will be needed to further reduce symptom burden at the end of life.
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Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Evelyne A Gahbauer
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Linda Leo-Summers
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terrence E Murphy
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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22
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Achterhof AB, Rozsnyai Z, Reeve E, Jungo KT, Floriani C, Poortvliet RKE, Rodondi N, Gussekloo J, Streit S. Potentially inappropriate medication and attitudes of older adults towards deprescribing. PLoS One 2020; 15:e0240463. [PMID: 33104695 PMCID: PMC7588126 DOI: 10.1371/journal.pone.0240463] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe. METHOD We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness. RESULTS Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81). CONCLUSION The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.
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Affiliation(s)
- Alexandra B. Achterhof
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
- Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Carmen Floriani
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | | | - Nicolas Rodondi
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
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23
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Abstract
A personal top ten list of literature about aging and the practice of geriatrics is offered. This is primarily directed at those completing their training in the care of older patients. While acknowledging the limitations of any such exercise, it is hoped that it will engender interest in prior work by and about older persons and their care. Those at the start of their careers in geriatrics are encouraged to read these and other primary contributions, make their own list of essential literature, and incorporate the lessons learned and the examples of prior practitioners into their professional practice.
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Affiliation(s)
- David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB
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24
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Izza MAD, Lunt E, Gordon AL, Gladman JRF, Armstrong S, Logan P. Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study. Eur Geriatr Med 2020; 11:1043-1050. [PMID: 32813154 PMCID: PMC7716922 DOI: 10.1007/s41999-020-00376-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/30/2020] [Indexed: 12/18/2022]
Abstract
Aim
To explore the link between polypharmacy, psychotropic medications, and falls risk in a cohort of UK care home residents. Findings
Polypharmacy and psychotropic drugs are predictive of falls in UK care home residents. Message Deprescribing interventions relating to psychotropic drugs should continue to be encouraged. Purpose Falls and polypharmacy are both common in care home residents. Deprescribing of medications in residents with increased falls risk is encouraged. Psychotropic medications are known to increase falls risk in older adults. These drugs are often used in care home residents for depression, anxiety, and behavioural and psychological symptoms of dementia. However, a few studies have explored the link between polypharmacy, psychotropic medications, and falls risk in care home residents. Methods This was a prospective cohort study of residents from 84 UK care homes. Data were collected from residents’ care records and medication administration records. Age, diagnoses, gender, number of medications, and number of psychotropic medications were collected at baseline and residents were monitored over three months for occurrence of falls. Logistic regression models were used to assess the effect of multiple medications and psychotropic medication on falls whilst adjusting for confounders. Results Of the 1655 participants, mean age 85 (SD 8.9) years, 67.9% female, 519 (31%) fell in 3 months. Both the total number of regular drugs prescribed and taking ≥ 1 regular psychotropic medication were independent risk factors for falling (adjusted odds ratio (OR) 1.06 (95% CI 1.03–1.09, p < 0.01) and 1.39 (95% CI 1.10–1.76, p < 0.01), respectively). The risk of falls was higher in those taking antidepressants (p < 0.01) and benzodiazepines (p < 0.01) but not antipsychotics (p > 0.05). Conclusion In UK care homes, number of medications and psychotropic medications (particularly antidepressants and benzodiazepines) predicted falls. This information can be used to inform prescribing and deprescribing decisions.
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Affiliation(s)
| | - Eleanor Lunt
- School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham NIHR Biomedical Research Centre - Musculoskeletal Theme, Nottingham, UK
| | - Adam L Gordon
- School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham NIHR Biomedical Research Centre - Musculoskeletal Theme, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK
| | - John R F Gladman
- School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham NIHR Biomedical Research Centre - Musculoskeletal Theme, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK
| | - Sarah Armstrong
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, UK.,Nottingham NIHR Biomedical Research Centre - Musculoskeletal Theme, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK.,Nottingham CityCare Partnership, Nottingham, UK
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25
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Abstract
Deprescribing is a holistic process to identify medications that can be ceased, substituted or reduced. This process can improve the health of older patients and also enhance their compliance to the prescribed medications which are actually beneficial. Recommendations and guidelines have been elaborated for extensively prescribed drugs. In clinical cardiology the process of deprescribing is a challenge for doctors because of withdrawal-related adverse effects, but it may be applied in certain clinical conditions such as the discontinuation of statin prescription in patients with advanced senile dementia and those with limited life expectancy. Deprescribing is also focussed on the scarcely known effects of prolonged therapy after the acute phase of a disease is over, especially when continuation may signify potential life-long treatment. There needs to be collaboration between the consultant cardiologist who first prescribes medications and family doctors who are responsible for the long-term care of the patient and reviewing prescribed medications may be necessary.
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26
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Wright DJ, Scott S, Buck J, Bhattacharya D. Role of nurses in supporting proactive deprescribing. Nurs Stand 2020; 34:44-50. [PMID: 31468926 DOI: 10.7748/ns.2019.e11249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 01/15/2023]
Abstract
Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.
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Affiliation(s)
| | - Sion Scott
- School of Pharmacy, University of East Anglia, Norwich, England
| | - Jackie Buck
- School of Health Sciences, University of East Anglia, Norwich, England
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27
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Forget MF, McDonald EG, Shema AB, Lee TC, Wang HT. Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort. Drugs Real World Outcomes 2020; 7:171-178. [PMID: 32306300 PMCID: PMC7221107 DOI: 10.1007/s40801-020-00190-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Few studies have evaluated the prevalence of potentially inappropriate medications (PIMs) and its association with postoperative outcomes in a geriatric population in the preoperative setting. Objectives The purpose of this study was to evaluate the prevalence of PIMs in an older elective surgery population and to explore associations between PIMs and postoperative length of stay (LOS) and emergency department (ED) visits in the 90 days post hospital discharge, depending on frailty status. Methodology We performed a retrospective cohort study of older adults awaiting major elective noncardiac surgery and undergoing an evaluation in the preoperative clinic at a tertiary academic center between 2017 and 2018. We identified PIMs using MedSafer, a software tool built to improve the safety of prescribing. Frailty status was assessed using the 7-point Clinical Frailty Scale. We estimated the association between PIMs and postoperative LOS and ED visits in the 90 days post hospital discharge. Results The MedSafer software generated 394 recommendations on PIMs in 1619 medications for 252 patients. In total, 197 (78%) patients had at least one PIM. The cohort included 138 (51%) robust, 87 (32.2%) vulnerable and 45 (16.7%) frail patients. The association between PIMs and LOS was not significant for the robust and frail subgroups. For the vulnerable patients, every additional PIM increased LOS by 20% (incidence rate ratio 1.20; 95% confidence interval 0.90–1.44; p = 0.089) without reaching statistical significance. No association was found between PIMs and ED visits. Conclusion PIMs identified by the MedSafer software were prevalent. Preoperative evaluation represents an opportunity to plan deprescribing of PIMs. Electronic supplementary material The online version of this article (10.1007/s40801-020-00190-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie-France Forget
- Division of Geriatric Medicine, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
| | - Emily Gibson McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Center, Montreal, QC, Canada.,Center for Health Outcomes Research and Evaluation, Research Institute-McGill University Health Center, Montreal, QC, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Center, Montreal, QC, Canada
| | | | - Todd Campbell Lee
- Division of General Internal Medicine, Department of Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Han Ting Wang
- Division of Internal and Critical Care Medicine, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, QC, Canada
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28
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Hung WW, Chow S. Optimizing Medication Use in Older Adults. Clin Ther 2020; 42:556-558. [PMID: 32284190 DOI: 10.1016/j.clinthera.2020.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/15/2022]
Affiliation(s)
- William W Hung
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Stephanie Chow
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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29
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Efficacy of calcitonin for treating acute pain associated with osteoporotic vertebral compression fracture: an updated systematic review. CAN J EMERG MED 2020; 22:359-367. [DOI: 10.1017/cem.2019.490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjectiveAcutely painful osteoporotic vertebral compression fractures are associated with hospitalization and mortality in older adults. Calcitonin may be an alternative to opioid or nonopioid analgesia for treating acute compression fracture pain in emergency and primary care settings. This review summarizes pain, function, and adverse events associated with calcitonin.MethodsWe searched MEDLINE, EMBASE, The Cochrane Library, clinical trials registries, and reference lists of included studies. Eligible studies evaluated the effect of synthetic calcitonins (salmon, eel, and human) on pain scores in adults ≥60 years old with a recent atraumatic compression fracture. Two reviewers screened studies, extracted data, and allocated bias in duplicate. A random effects meta-analysis evaluated standard mean difference (SMD) and heterogeneity (I2).ResultsOf 1,198 articles screened, 11 were included (9 in the meta-analysis). Treatment lasted from 14 days to 6 months. Pain was lower in the salmon calcitonin group (100–200 IU IM or NAS, daily) than the control group with high certainty of evidence at week 1 (SMD, -1.54; 95% confidence interval [CI], -2.02 – -1.06; I2 = 52%), representing a number needed to treat of two. The analgesic efficacy of salmon calcitonin at 4 weeks was unclear due to substantial heterogeneity. There was low certainty evidence that calcitonin did not increase the overall risk of adverse events, including nausea and vomiting (risk ratio, 2.10; 95% CI, 0.87–5.08; I2 = 47%).ConclusionsCalcitonin is beneficial and appears safe for treating acute pain associated with compression fractures. Further studies may improve the certainty of evidence.
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30
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Kouladjian O’Donnell L, Sawan M, Reeve E, Gnjidic D, Chen TF, Kelly PJ, Bell JS, Hilmer SN. Implementation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© into home medicines review: a protocol for a cluster-randomised clinical trial in older adults. BMC Geriatr 2020; 20:51. [PMID: 32050899 PMCID: PMC7017507 DOI: 10.1186/s12877-020-1442-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/23/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Older people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes. METHODS This study consists of 2 stages: Stage I - a two-arm parallel-group cluster-randomised clinical trial, and Stage II - process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients' goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient's GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS). OUTCOMES The primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR. DISCUSSION This study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults. TRIAL REGISTRATION The trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.
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Affiliation(s)
- Lisa Kouladjian O’Donnell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
| | - Mouna Sawan
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
- Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
- College of Medicine, University of Saskatchewan, Saskatchewan, Canada
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, South Australia Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW Australia
| | - Timothy F. Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Patrick J. Kelly
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - J. Simon Bell
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria Australia
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria Australia
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia Australia
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership Centre, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065 Australia
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31
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Alkabbani W, Marrie RA, Bugden S, Alessi-Severini S, Bolton JM, Daeninck P, Leong C. Persistence of use of prescribed cannabinoid medicines in Manitoba, Canada: a population-based cohort study. Addiction 2019; 114:1791-1799. [PMID: 31240747 DOI: 10.1111/add.14719] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/11/2019] [Accepted: 06/14/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS To estimate prevalence of continuous use (persistence) of prescribed cannabinoid medications for up to 1 year from initial prescription in Manitoba, Canada and predictors of duration of use. DESIGN AND SETTING A retrospective, population-based, cohort study using administrative data from the Manitoba Population Research Data Repository located at the Manitoba Centre for Health Policy, Canada. PARTICIPANTS People without a record of a previous prescription who were prescribed a cannabinoid medication from 1 April 2004 to 1 April 2016 followed for 1 year from the date of first prescription. MEASUREMENTS Continuous prescribed cannabinoid medication use was defined as use without a gap exceeding 60 days between prescriptions. The primary outcome was prevalence of continuous prescribed cannabinoid medication use for up to 1 year. A secondary outcome was duration of continuous use. Predictors were socio-demographic characteristics, medical diagnoses and type of cannabinoid medication. FINDINGS Among 5452 new users, 18.1% [95% confidence interval (CI) = 17.08-19.12] were still using cannabinoids at 1 year. Median duration of use was 31 days [interquartile range (IQR) = 25-193]. This was highest for nabilone (33 days, IQR = 25-199) and lowest for nabiximols (20 days, IQR = 7-30). Use was longest among 19-45- and 46-64-year-old users and those with the highest socio-economic status. Fibromyalgia [hazard ratio (HR) = 0.89, 95% CI = 0.84-0.95], osteoarthritis (HR = 0.91, 95% CI = 0.82-0.97) and substance use disorder (HR = 0.85, 95% CI = 0.76-0.94) diagnoses were associated with longer use (HR for discontinuation-HR < 1 less discontinuation and longer use). A diagnosis of cancer was associated with shorter use (HR = 2.73, 95% CI = 2.02-3.67). CONCLUSIONS In Manitoba, Canada approximately 18% of people prescribed cannabinoid medication continue using for at least 1 year. Duration of use varies with type of cannabinoid medication, age, socio-economic status and dagnosis.
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Affiliation(s)
- Wajd Alkabbani
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruth Ann Marrie
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,School of Pharmacy, Memorial University of Newfoundland, St John's, Newfoundland, Canada
| | - Silvia Alessi-Severini
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M Bolton
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Daeninck
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christine Leong
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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32
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Greiver M, Dahrouge S, O’Brien P, Manca D, Lussier MT, Wang J, Burge F, Grandy M, Singer A, Twohig M, Moineddin R, Kalia S, Aliarzadeh B, Ivers N, Garies S, Turner JP, Farrell B. Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada. Implement Sci 2019; 14:55. [PMID: 31171011 PMCID: PMC6551894 DOI: 10.1186/s13012-019-0904-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/13/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. METHODS This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes. CONCLUSION We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. TRIAL REGISTRATION Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.
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Affiliation(s)
- M. Greiver
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - S. Dahrouge
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario K1R 6M1 Canada
- Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario K1N 5C8 Canada
| | - P. O’Brien
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - D. Manca
- Department of Family Medicine, University of Alberta, 8303 - 112 Street NW, 610 University Terrace, Edmonton, Alberta T6G 2T4 Canada
| | - M. T. Lussier
- Department of Family Medicine and Emergency Medicine, University of Montreal, 1755 René Laennec, Bureau DS-079, Laval, Québec H7M3L9 Canada
| | - J. Wang
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - F. Burge
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans’ Memorial Lane, Halifax, Nova Scotia B3H 2E2 Canada
| | - M. Grandy
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans’ Memorial Lane, Halifax, Nova Scotia B3H 2E2 Canada
| | - A. Singer
- Department of Family Medicine, University of Manitoba, D009 – 780 Bannatyne Ave, Winnipeg, Manitoba R3T 2N2 Canada
| | - M. Twohig
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - R. Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
| | - S. Kalia
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - B. Aliarzadeh
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - N. Ivers
- Family Practice Health Centre and Women’s College Research Institute, Women’s College Hospital, 76 Grenville Street, Toronto, Ontario M5S 1B2 Canada
| | - S. Garies
- Department of family Medicine, Cumming School of Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - J. P. Turner
- Faculty of Pharmacy, University of Montreal, 2900 Edouard Montpetit Boulevard, Montreal, Quebec H3T 1J4 Canada
- Centre de Recherche, Institut Universitaire de Geriatrie de Montreal, Montreal, Canada
| | - B. Farrell
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario K1R 6M1 Canada
- Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario K1N 5C8 Canada
- School of Pharmacy, University of Waterloo, Waterloo, Canada
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Szilvay A, Somogyi O, Meskó A, Zelkó R, Hankó B. Qualitative and quantitative research of medication review and drug-related problems in Hungarian community pharmacies: a pilot study. BMC Health Serv Res 2019; 19:282. [PMID: 31053135 PMCID: PMC6499984 DOI: 10.1186/s12913-019-4114-1] [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: 11/23/2018] [Accepted: 04/22/2019] [Indexed: 01/04/2023] Open
Abstract
Background Pharmaceutical care is the pharmacist’s contribution to the care of individuals to optimize medicines use and improve health outcomes. The primary tool of pharmaceutical care is medication review. Defining and classifying Drug-Related Problems (DRPs) is an essential pillar of the medication review. Our objectives were to perform a pilot of medication review in Hungarian community pharmacies, a DRP classification was applied for the first time. Also, our goal was the qualitative and quantitative description of the discovered DRPs, and of the interventions for their solution in order to prove the safety relevance of the service and to map out the competence limits of GPs and community pharmacists to drug therapy. Methods The project took place in Hungarian community pharmacies. The study was performed with patients taking vitamin K antagonist (VKA) and/or ACE inhibitor and NSAID simultaneously (ACEI-NSAID). 61 pharmacists and 606 patients participated in the project. Pharmacists reviewed the medication for 3 months and the classification of DRPs was performed (category of DRP1 – DRP6). Patient data were statistically analyzed. Results Patients consumed on average 7.9 ± 3.1 medications and other products. 571 DRPs were detected in 540 patients, averaging 1.06 DRPs per patient (SD = 1.07). The highest frequency category was DRP5 (non-quantitative safety problem; 51.0%). The most common root cause was an interaction (42.0%) and non-adherence (19.4%.). The most commonly used intervention was education (25.4%) and medication replacement by the pharmacist (20.1%). The changing of the frequency and dosage in any direction were negligible. Conclusions Patients are struggling with many DRPs that can be assessed and categorized by this system and which remain unrecognizable without pharmacists. Further projects need to be developed to assist in the development of physician-pharmacist cooperation and the widespread dissemination of pharmaceutical care.
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Affiliation(s)
- András Szilvay
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Hungary; 7-9 Hőgyes Endre street, Budapest, H-1092, Hungary
| | - Orsolya Somogyi
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Hungary; 7-9 Hőgyes Endre street, Budapest, H-1092, Hungary
| | - Attiláné Meskó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Hungary; 7-9 Hőgyes Endre street, Budapest, H-1092, Hungary
| | - Romána Zelkó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Hungary; 7-9 Hőgyes Endre street, Budapest, H-1092, Hungary
| | - Balázs Hankó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Hungary; 7-9 Hőgyes Endre street, Budapest, H-1092, Hungary.
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Effectiveness and feasibility of deprescribing of symptomatic medications in a Singapore rehabilitation hospital. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105818782006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: This study aims to determine the effectiveness, cost savings and feasibility of implementing a systematic process of deprescribing medications for symptomatic management, namely, acid suppressants, laxatives, analgesics and antiemetics for patients of a Singapore rehabilitation hospital. Methods: A total of 200 patients were randomized to a deprescribing intervention ( n = 100) or control (usual care) group ( n = 100). The patient-centred deprescribing process was utilized. Symptomatic medications were deprescribed following initial pharmacist assessment, discussion with doctors and consideration of patients’ preferences regarding discontinuation or dose reduction. Symptom recurrence, adverse drug withdrawal events (ADWEs) and the need for drug re-initiation or initiation of new symptomatic medications after deprescribing were monitored in the first, second and sixth weeks. Results: The mean age of patients was 72.8 years and 68.6 years in the intervention and control groups. There were no significant reductions in the monthly cost and total number of medications between both intervention and control groups. Systematic deprescribing of acid suppressants was the highest among the four target drug classes. Recurrence of pain and re-initiation of analgesics occurred in two out of seven cases of discontinuation. However, no ADWEs or constipation were noted in the intervention group. On average, a total of 19 minutes was required by pharmacists and doctors to complete the deprescribing process. Conclusion: The systematic deprescribing of symptomatic medications did not reduce costs nor the total number of medications. The risk of symptom recurrence and adverse events was negligible. Knowledge, attitudes and collaboration among healthcare professionals regarding deprescribing are critical. Trial registration: Clinicaltrials.gov, number NCT03354845.
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Niehoff KM, Mecca MC, Fried TR. Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies. Ther Adv Drug Saf 2019; 10:2042098618815431. [PMID: 30719279 PMCID: PMC6348576 DOI: 10.1177/2042098618815431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/04/2018] [Indexed: 01/05/2023] Open
Abstract
Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.
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Affiliation(s)
- Kristina M. Niehoff
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcia C. Mecca
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Terri R. Fried
- VA Connecticut Healthcare System, CERC 151B, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT USA
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Sultana J, Giorgianni F, Rea F, Lucenteforte E, Lombardi N, Mugelli A, Vannacci A, Liperoti R, Kirchmayer U, Vitale C, Chinellato A, Roberto G, Corrao G, Trifirò G. All-cause mortality and antipsychotic use among elderly persons with high baseline cardiovascular and cerebrovascular risk: a multi-center retrospective cohort study in Italy. Expert Opin Drug Metab Toxicol 2019; 15:179-188. [PMID: 30572727 DOI: 10.1080/17425255.2019.1561860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Little is known about the comparative risk of death with atypical or conventional antipsychotics (APs) among persons with cardiovascular or cerebrovascular disease (CCD). RESEARCH DESIGN AND METHODS A cohort study was conducted using five Italian claims databases. New atypical AP users with CCD aged ≥65 (reference) were matched to new conventional AP users. Mortality per 100 person-years (PYs) and hazard ratios (HR), estimated using Cox models, were reported. Incidence and risk of death were estimated for persons having drug-drug interactions. Outcome occurrence was evaluated 180 days after AP initiation. RESULTS Overall 24,711 and 27,051 elderly new conventional and atypical AP users were identified. The mortality rate was 51.3 and 38.5 deaths per 100 PYs for conventional and atypical AP users. Mortality risk was 1.33 (95%CI: 1.27-1.39) for conventional APs. There was no increased mortality risk with single drug-drug interactions (DDIs) vs. no DDI. AP users with ≥1 DDI had a 29% higher mortality risk compared to no DDI in the first 90 days of treatment (HR: 1.29 (95% CI: 1.00-1.67)). CONCLUSIONS Conventional APs had a higher risk of death than atypical APs among elderly persons with CCD. Having ≥1 DDI was associated with an increased risk of death.
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Affiliation(s)
- Janet Sultana
- a Department of Biomedical and Dental Sciences and Morphofunctional Imaging , University of Messina , Messina , Italy
| | - Francesco Giorgianni
- a Department of Biomedical and Dental Sciences and Morphofunctional Imaging , University of Messina , Messina , Italy
| | - Federico Rea
- b Laboratory of Pharmacoepidemiology & Healthcare Research , University of Milano-Bicocca , Milan , Italy
| | - Ersilia Lucenteforte
- c Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Niccolò Lombardi
- d Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA) , University of Florence , Florence , Italy
| | - Alessandro Mugelli
- d Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA) , University of Florence , Florence , Italy
| | - Alfredo Vannacci
- d Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA) , University of Florence , Florence , Italy
| | - Rosa Liperoti
- e Department of Geriatrics, University Hospital A. Gemelli IRCCS , Rome - Catholic University of the Sacred Heart , Rome , Italy
| | | | - Cristiana Vitale
- g Department of Medical Sciences , IRCCS San Raffaele Pisana , Rome , Italy
| | - Alessandro Chinellato
- h Unit of Pharmaceutical Policy and Budget Management , Healthcare Unit ULSS 9 of Treviso , Italy
| | | | - Giovanni Corrao
- b Laboratory of Pharmacoepidemiology & Healthcare Research , University of Milano-Bicocca , Milan , Italy
| | - Gianluca Trifirò
- a Department of Biomedical and Dental Sciences and Morphofunctional Imaging , University of Messina , Messina , Italy.,j i-GrADE consortium: Nera Agabiti, Claudia Bartolini, Roberto Bernabei, Alessandra Bettiol, Stefano Bonassi, Achille Patrizio Caputi, Silvia Cascini, Alessandro Chinellato, Francesco Cipriani, Giovanni Corrao, Marina Davoli, Massimo Fini, Rosa Gini, Francesco Giorgianni, Ursula Kirchmayer, Francesco Lapi, Niccolò Lombardi, Ersilia Lucenteforte, Alessandro Mugelli, Graziano Onder, Federico Rea, Giuseppe Roberto, Chiara Sorge, Janet Sultana, Michele Tari, Gianluca Trifirò, Alfredo Vannacci, Davide Liborio Vetrano, Cristiana Vitale
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Gill TM, Allore HG, Gahbauer EA, Murphy TE. Burden of Restricted Activity and Associated Symptoms and Problems in Late Life and at the End of Life. J Am Geriatr Soc 2018; 66:2282-2288. [PMID: 30277571 PMCID: PMC6607906 DOI: 10.1111/jgs.15566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To compare rates of restricted activity and associated symptoms and problems in the last 6 months of life with those in the period before the last 6 months of life. DESIGN Prospective cohort study. SETTING Greater New Haven, Connecticut. PARTICIPANTS Community-living persons aged 70 and older (N=754). MEASUREMENTS The occurrence of restricted activity (staying in bed for at least half the day or cutting down on usual activities) and 24 prespecified symptoms and problems leading to restricted activity was ascertained monthly for nearly 19 years. RESULTS Rates of restricted activity per 100 person-months were 36.5 in the last 6 months of life versus 16.1 in the period before the last 6 months of life (P<.001). Of 737 participants with 1 month or more of restricted activity, rates of restricting symptoms per 100 person-months of restricted activity ranged from 8.0 for frequent or painful urination to 65.6 for been fatigued, and rates of restricting problems ranged from 0.1 for problem with alcohol to 23.4 for been afraid of falling. Rates were significantly higher in the last 6 months of life than in the prior period for 13 of the 24 restricting symptoms and problems (P<.05), most notably for shortness of breath (38.6 vs 21.8), weakness (37.3 vs 18.9), and confusion (31.2 vs 9.8). Mean (standard error) number of restricting symptoms and problems was significantly higher in the last 6 months of life (6.1 (0.1)) than in the prior period (4.7 (0.03)) (P<.001). CONCLUSION Rates of restricted activity and associated symptoms and problems are substantially greater in the last 6 months of life than in the period before the last 6 months of life. Enhanced palliative care strategies may be needed to diminish the burden of distressing symptoms and problems at the end of life. J Am Geriatr Soc 66:2282-2288, 2018.
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Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Heather G Allore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Evelyne A Gahbauer
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Terrence E Murphy
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Hansen CR, O'Mahony D, Kearney PM, Sahm LJ, Cullinan S, Huibers C, Thevelin S, Rutjes AW, Knol W, Streit S, Byrne S. Identification of behaviour change techniques in deprescribing interventions: a systematic review and meta-analysis. Br J Clin Pharmacol 2018; 84:2716-2728. [PMID: 30129139 PMCID: PMC6255994 DOI: 10.1111/bcp.13742] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 07/31/2018] [Accepted: 08/12/2018] [Indexed: 12/19/2022] Open
Abstract
AIMS Deprescribing interventions safely and effectively optimize medication use in older people. However, questions remain about which components of interventions are key to effectively reduce inappropriate medication use. This systematic review examines the behaviour change techniques (BCTs) of deprescribing interventions and summarizes intervention effectiveness on medication use and inappropriate prescribing. METHODS MEDLINE, EMBASE, Web of Science and Academic Search Complete and grey literature were searched for relevant literature. Randomized controlled trials (RCTs) were included if they reported on interventions in people aged ≥65 years. The BCT taxonomy was used to identify BCTs frequently observed in deprescribing interventions. Effectiveness of interventions on inappropriate medication use was summarized in meta-analyses. Medication appropriateness was assessed in accordance with STOPP criteria, Beers' criteria and national or local guidelines. Between-study heterogeneity was evaluated by I-squared and Chi-squared statistics. Risk of bias was assessed using the Cochrane Collaboration Tool for randomized controlled studies. RESULTS Of the 1561 records identified, 25 studies were included in the review. Deprescribing interventions were effective in reducing number of drugs and inappropriate prescribing, but a large heterogeneity in effects was observed. BCT clusters including goals and planning; social support; shaping knowledge; natural consequences; comparison of behaviour; comparison of outcomes; regulation; antecedents; and identity had a positive effect on the effectiveness of interventions. CONCLUSIONS In general, deprescribing interventions effectively reduce medication use and inappropriate prescribing in older people. Successful deprescribing is facilitated by the combination of BCTs involving a range of intervention components.
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Affiliation(s)
- Christina R. Hansen
- Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy BuildingUniversity College CorkCorkIreland
- Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagen ØDenmark
| | - Denis O'Mahony
- Department of MedicineUniversity College CorkCorkIreland
- Department of Geriatric MedicineCork University HospitalCorkIreland
| | | | - Laura J. Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy BuildingUniversity College CorkCorkIreland
- Pharmacy DepartmentMercy University HospitalCorkIreland
| | - Shane Cullinan
- School of Pharmacy, Royal College of Surgeons of IrelandDublinIreland
| | - C.J.A. Huibers
- Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old PersonsUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Stefanie Thevelin
- Clinical Pharmacy Research Group, Louvain Drug Research InstituteUniversité Catholique de LouvainBrusselsBelgium
| | - Anne W.S. Rutjes
- Institute of Social and Preventive MedicineUniversity of Bern, Switzerland & Institute of Primary Health Care (BIHAM), University of BernSwitzerland
| | - Wilma Knol
- Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old PersonsUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Sven Streit
- Institute of Primary Health Care (BIHAM)University of BernBernSwitzerland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy BuildingUniversity College CorkCorkIreland
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Yu F, Rafizadeh R, Mabasa VH, Kang N. Risk Evaluation for Antipsychotic Agents Used in Elderly Inpatients (REPAIR). Can J Hosp Pharm 2018; 71:370-375. [PMID: 30626983 PMCID: PMC6306184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Antipsychotics have been approved for the treatment of certain psychiatric illnesses. However, these medications are also frequently used off label, and recent studies have suggested a concerning potential increase in the risk of death when used by elderly patients with dementia. Most of the available literature focusing on off-label use of antipsychotics comes from long-term care facilities; there is a lack of quantitative data for elderly patients in the acute care setting. This study was designed to examine this scenario and to identify potential quality improvement opportunities to minimize harm. OBJECTIVES The primary objectives were to determine the prevalence of hospital-initiated off-label use of antipsychotics for elderly inpatients and to determine the plan for these drugs upon discharge. The secondary objectives included identifying the most common diagnosis and the most common agent used. METHODS A retrospective cohort study was performed with a convenience sample. Patients included in the analysis were elderly adults (≥ 65 years) who had been admitted to either of 2 medical units at a community hospital between September 1 and November 8, 2014. Descriptive statistics were used to examine prevalence patterns for the off-label use of antipsychotics. RESULTS A total of 250 patients were included in the analysis. Forty-five patients (18%, 95% confidence interval [CI] 13.7%-23.2%) received a hospital-initiated antipsychotic for off-label use during the admission. For 27 (60%, 95% CI 45.5%-73.0%) of these 45 patients, the off-label therapy was discontinued upon discharge or death, and for 13 (29%, 95% CI 17.7%-43.4%), the agent was continued upon discharge without a plan in place. The most frequent diagnosis was delirium, and the agent most frequently used was haloperidol. CONCLUSIONS Off-label antipsychotic therapy was initiated for almost 1 in every 5 elderly patients receiving care in 2 medical units at a community hospital. These findings suggest a need to monitor and reassess the off-label use of these agents, especially at the time of discharge.
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Affiliation(s)
- Flora Yu
- BSc(Pharm), ACPR, is a Clinical Pharmacist with Vancouver General Hospital, Vancouver, British Columbia
| | - Reza Rafizadeh
- BSc(Pharm), ACPR, BCPP, is a Clinical Pharmacist in Mental Health and Substance Use with the Burnaby Centre for Mental Health & Addiction, Burnaby, British Columbia
| | - Vincent H Mabasa
- BSc(Pharm), ACPR, PharmD, is Clinical Coordinator with the Burnaby Hospital, Burnaby, British Columbia
| | - Nirmal Kang
- MBBS, FRCPC, is a Psychiatrist with the Burnaby Hospital, Burnaby, British Columbia
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Thompson W, Lundby C, Graabaek T, Nielsen DS, Ryg J, Søndergaard J, Pottegård A. Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc 2018; 67:172-180. [DOI: 10.1111/jgs.15616] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Dorthe S. Nielsen
- Migrant Health Clinic; Odense University Hospital; Odense Denmark
- Centre for Global Health; University of Southern Denmark; Odense Denmark
- Health Sciences Research Center; University College Lillebaelt; Odense Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine; Odense University Hospital; Odense Denmark
- Geriatric Research Unit, Department of Clinical Research; University of Southern Denmark; Odense Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
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Wan A, Halpape K, Talkhi SC, Dixon C, Dossa H, Tabamo J, Roberts M, Dahri K. Evaluation of Prescribing Appropriateness and Initiatives to Improve Prescribing of Proton Pump Inhibitors at Vancouver General Hospital. Can J Hosp Pharm 2018; 71:308-315. [PMID: 30401997 PMCID: PMC6209498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) have proven clinical efficacy for a variety of indications. However, there is emerging evidence of adverse events associated with their long-term use. The emergence of these adverse events has reinforced the need to regularly evaluate the appropriateness of continuing PPI therapy, and to use only the lowest effective dose for the minimally indicated duration. OBJECTIVES To characterize the appropriateness of PPI orders continued or initiated in the internal medicine and family practice units of Vancouver General Hospital, to detect adverse events associated with PPI use, and to explore the impact of multidisciplinary teaching and provision of educational resources on health care practitioners' views about PPI use. METHODS A chart review was conducted for patients admitted (for at least 24 hours) between January 1 and December 31, 2015, for whom a hospital formulary PPI was prescribed. An educational initiative, which included interprofessional in-service sessions, a PPI prescribing infographic, a PPI prescribing card, and a patient counselling sheet, was implemented. The impact of these interventions was assessed using a qualitative survey of health care practitioners. RESULTS Of the 258 patients whose charts were reviewed, 175 had a PPI prescription before hospital admission, and 83 were initiated on PPI therapy during their hospital stay. Overall, 94 (36%) of the patients were receiving PPIs without an appropriate indication. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. In-service sessions and educational resources on PPI prescribing were reported to affect the clinical practice of 24 (52%) of the 46 survey respondents. CONCLUSIONS The results of this study emphasize the need for ongoing re-evaluation of long-term PPI therapy at the time of admission, during the hospital stay, and upon discharge. Implementing multidisciplinary teaching and providing educational resources may encourage more appropriate prescribing.
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Affiliation(s)
- Andrea Wan
- , BSc(Pharm), ACPR, is with the Department of Pharmacy, St Paul's Hospital, Vancouver, British Columbia
| | - Katelyn Halpape
- , BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia
| | - Shirin C Talkhi
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Claire Dixon
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Hafeez Dossa
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Jenifer Tabamo
- , RN, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Mark Roberts
- , MD, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BSc(Pharm), ACPR, PharmD, is with the Faculty of Pharmaceutical Sciences, The University of British Columbia, and the Department of Pharmacy Vancouver General Hospital, Vancouver, British Columbia
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Clevenger CK, Cellar J, Kovaleva M, Medders L, Hepburn K. Integrated Memory Care Clinic: Design, Implementation, and Initial Results. J Am Geriatr Soc 2018; 66:2401-2407. [DOI: 10.1111/jgs.15528] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 06/05/2018] [Accepted: 10/10/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Carolyn K. Clevenger
- Nell Hodgson Woodruff School of NursingEmory University Atlanta Georgia
- Integrated Memory Care Clinic, Emory Healthcare Atlanta Georgia
| | - Janet Cellar
- Integrated Memory Care Clinic, Emory Healthcare Atlanta Georgia
- Department of NeurologyEmory University Atlanta Georgia
- Alzheimer's Disease Research CenterEmory University Atlanta Georgia
| | - Mariya Kovaleva
- Nell Hodgson Woodruff School of NursingEmory University Atlanta Georgia
| | - Laura Medders
- Integrated Memory Care Clinic, Emory Healthcare Atlanta Georgia
| | - Kenneth Hepburn
- Nell Hodgson Woodruff School of NursingEmory University Atlanta Georgia
- Alzheimer's Disease Research CenterEmory University Atlanta Georgia
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Al-Dahhak R, Khoury R, Qazi E, Grossberg GT. Traumatic Brain Injury, Chronic Traumatic Encephalopathy, and Alzheimer Disease. Clin Geriatr Med 2018; 34:617-635. [PMID: 30336991 DOI: 10.1016/j.cger.2018.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a major health and economic burden. With increasing aging population, this issue is expected to continue to rise. Neurodegenerative disorders are more common with aging population in general regardless of history of TBI. Recent evidence continues to support a relation between a TBI and neurocognitive decline later in life (such as in athletes and military). This article summarizes the pathologic and clinical effects of TBI (regardless of severity) on the later development of dementia in individuals 65 years or older.
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Affiliation(s)
- Roula Al-Dahhak
- Department of Neurology, Saint Louis University, 1438 South Grand Boulevard, Suite 105, St Louis, MO 63104, USA.
| | - Rita Khoury
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
| | - Erum Qazi
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
| | - George T Grossberg
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University, 1438 South Grand Boulevard, St Louis, MO 63104, USA
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Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, Woo J, Dong B, de la Vega S, Hua Poi PJ, Kamaruzzaman SBB, Won C, Chen LK, Rockwood K, Arai H, Rodriguez-Mañas L, Cao L, Cesari M, Chan P, Leung E, Landi F, Fried LP, Morley JE, Vellas B, Flicker L. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc 2018. [PMID: 28648901 DOI: 10.1016/j.jamda.2017.04.018] [Citation(s) in RCA: 370] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. METHODS An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. RECOMMENDATIONS Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. CONCLUSIONS The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.
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Affiliation(s)
- Elsa Dent
- Center for Research in Geriatric Medicine, School of Medicine, The University of Queensland, Brisbane, Australia.
| | - Christopher Lien
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wei Chin Wong
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore, Singapore
| | - Tze Pin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jean Woo
- The S H Ho Center for Gerontology and Geriatrics, The Chinese University of Hong Kong, Hong Kong, China
| | - Birong Dong
- Geriatrics Center Huaxi Hospital, Sichuan University, Chengdu, China
| | - Shelley de la Vega
- University of the Philippines College of Medicine, Manila, Philippines; Institute on Aging, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Philip Jun Hua Poi
- Division of Geriatrics, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Chang Won
- Department of Family Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital; Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | | | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Obu, Japan
| | | | - Li Cao
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | | | - Piu Chan
- Department of Geriatrics, Neurology, and Neurobiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Edward Leung
- Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong
| | | | - Linda P Fried
- Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | - John E Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University, St. Louis, MO
| | | | - Leon Flicker
- Western Australia Center for Health and Aging, University of Western Australia, Perth, Australia
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Changes in medicine prescription following a medication review in older high-risk patients with polypharmacy. Int J Clin Pharm 2018; 40:480-487. [PMID: 29453677 PMCID: PMC5918522 DOI: 10.1007/s11096-018-0602-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 02/01/2018] [Indexed: 12/02/2022]
Abstract
Background The more (inappropriate) drugs a patient uses, the higher the risk of drug related problems. To reduce these risks, medication reviews can be performed. Objective To report changes in the prescribed number of (potentially inappropriate) drugs before and after performing a medication review in high-risk polypharmacy patients. A secondary objective was to study reasons for continuing potentially inappropriate drugs (PIDs). Setting Dutch community pharmacy and general medical practice. Methods A retrospective longitudinal intervention study with a pre-test/post-test design and follow-up of 1 week and 3 months was performed. The study population consisted of 126 patients with polypharmacy and with additional risk for drug related problems that underwent a medication review in five community pharmacies. The medication review was performed by the pharmacist in close cooperation with the general practitioner of each corresponding patient. Main outcome measure Number of (potentially inappropriate) drugs, and appropriateness of prescribed medicines. Results The average number of drugs a patient used 1 day before the review was 8.7 (SD = 2.9), which decreased (p < 0.05) to 8.3 (SD = 2.7) 1 week after the review, and to 8.4 (SD = 2.6) 3 months after the review. The average number of PIDs was initially 0.6 (SD = 0.8) per patient and decreased to 0.4 (SD = 0.6, p < 0.05). Twenty-two of the 241 initial drug changes (9%) were deprescribed during follow-up. Registered reasons for continuing PIDs are clinical or patients’ preferences. Conclusions Performing medication reviews in polypharmacy patients seems useful to continue at least in high-risk patients in The Netherlands. The time-consuming reviews could be limited to patients who are willing to change their medication.
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Abstract
Due to the increasing age of the population, neurohospitalists are more frequently caring for old and very old people. Fundamental definitions and topics related to geriatric medicine are therefore of particular importance. In this review, common issues encountered in geriatric patients hospitalized on the neurology service are discussed. Focus is put on the geriatric assessment, multiprofessional diagnostic and therapeutic procedures, geriatric syndromes, pharmacotherapy of the aged, delirium, pain, and palliative management as they are relevant for the neurohospitalist. In addition, ethical questions are addressed.
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Affiliation(s)
- Josef G Heckmann
- Department of Neurology, Municipal Hospital Landshut, Landshut, Germany
| | - Jörg Kraus
- Department of Neurology, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburger Landeskliniken, Salzburg, Austria
| | - Christoph J G Lang
- Department of Neurology, Medical Faculty, University Hospital Erlangen, Erlangen, Germany
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Mate KS, Berman A, Laderman M, Kabcenell A, Fulmer T. Creating Age-Friendly Health Systems - A vision for better care of older adults. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:4-6. [PMID: 28774720 DOI: 10.1016/j.hjdsi.2017.05.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Abstract
Safe and effective care of older adults is a crucial issue given the rapid growth of the aging demographic, many of whom have complex health and social needs. At the same time, the health care delivery environment is rapidly changing, offering a new set of opportunities to improve care of older adults. We describe the background, evidence-based changes, and testing, scale-up, and spread strategy that are part of the design of the Creating Age-Friendly Health Systems initiative. The goal is to reach 20% of U.S. hospitals and health systems by 2020, with plans to reach additional hospitals and health systems in subsequent years.
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Affiliation(s)
- Kedar S Mate
- Institute for Healthcare Improvement (IHI), United States
| | - Amy Berman
- The John A. Hartford Foundation, United States
| | - Mara Laderman
- Institute for Healthcare Improvement (IHI), United States
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Cheong ST, Ng TM, Tan KT. Pharmacist-initiated deprescribing in hospitalised elderly: prevalence and acceptance by physicians. Eur J Hosp Pharm 2017; 25:e35-e39. [PMID: 31157064 DOI: 10.1136/ejhpharm-2017-001251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/02/2017] [Accepted: 07/11/2017] [Indexed: 11/04/2022] Open
Abstract
Objectives Deprescribing can help reduce polypharmacy in the elderly and hospitalisation presents an opportunity to re-evaluate the use of medications. The aim of this study was to describe the drugs that were commonly suggested by pharmacists to be deprescribed in hospitalised elderly, and the factors associated with acceptance by physicians. Methods A retrospective, cross-sectional study was conducted in a tertiary hospital in Singapore. All pharmacist interventions on deprescribing in inpatient elderly aged ≥65 years, made between July and December 2015 were included. Comparisons between groups were made and independent factors associated with physician acceptance were determined. Results A total of 503 interventions were included and 392 (77.9%) were accepted by physicians. Most interventions were on gastrointestinal agents (49.7%) and supplements (42.7%). The common reasons for deprescribing were: overduration of treatment (44.5%), unclear indication (23.9%) and the overdosage (20.7%). No significant differences were found between the reasons for deprescribing and acceptance by physicians. Use of <9 medications (OR 1.92, 95% CI 1.20 to 3.07), gastrointestinal agents (OR 3.46, 95% CI 1.06 to 11.26) and supplements (OR 3.20, 95% CI 1.06 to 9.69) were associated with higher physician acceptance (p<0.05). Conclusions In our cohort of hospitalised elderly, gastrointestinal agents and supplements were most commonly suggested by pharmacists to be deprescribed and at least three quarters of these interventions were accepted by physicians.
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Affiliation(s)
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | - Keng Teng Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
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Linsky A, Meterko M, Stolzmann K, Simon SR. Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing. BMC Health Serv Res 2017; 17:447. [PMID: 28659157 PMCID: PMC5490086 DOI: 10.1186/s12913-017-2391-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One approach to prevent adverse drug events is to discontinue ("deprescribe") medications that are outdated, not indicated, or of limited benefit relative to risk for a particular patient. However, there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice. We sought to determine clinical prescribers' preferences for interventions that would improve their ability to appropriately and proactively discontinue medications. METHODS We conducted a national web-based survey of 2475 prescribers [physicians, nurse practitioners (NP), physician assistants (PA), and clinical pharmacy specialists] practicing in US Veterans Affairs (VA) primary care clinics. One survey question presented 15 potential changes to medication-related practices and respondents ranked their top three choices for changes that would "most improve [their] ability to discontinue medications." We summed the weighted rankings for each of the 15 response options. Preferences were determined for the whole sample and within subgroups of respondents defined by demographic and background characteristics, medication-relevant experience, and beliefs. RESULTS Among the 326 respondents who provided rankings, the top choice for a change that would help improve their ability to discontinue medications was "Requiring all medication prescriptions to have an associated 'indication for use.'" This preference was followed by "Assistance with follow-up of patients as they taper or discontinue medications is performed by another member of the Patient Aligned Care Team (PACT)" and "Increased patient involvement in prescribing decisions." This combination of options, albeit in varying rank order, was the most commonly selected, with 250 respondents (77%) who answered the question including at least one of these items in their three highest ranked choices, regardless of their demographics, experience, or beliefs. CONCLUSIONS Continued efforts to improve clinicians' ability to make prescribing decisions, especially around deprescribing, have many potential benefits, including decreased pharmaceutical and health care costs, fewer adverse drug events and complications, and improved patient involvement and satisfaction with their care. Future work, whether as research or quality improvement, should incorporate clinicians' preferences for interventions, as greater buy-in from front-line staff leads to better adoption of changes.
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Affiliation(s)
- Amy Linsky
- Section of General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA. .,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA. .,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA.
| | - Mark Meterko
- Performance Measurement, VHA, Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID), Bedford, MA, USA.,Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA
| | - Steven R Simon
- Section of General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA.,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and ENRM Veterans Affairs Medical Center, 150 S. Huntington Ave, Boston, MA, USA.,Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
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Abstract
BACKGROUND AND OBJECTIVES Successful mechanisms for engaging patients in the deprescribing process remain unknown but may include: (1) triggering motivation to deprescribe by increasing patients' knowledge and concern about medications; (2) building capacity to taper by augmenting self-efficacy and (3) creating opportunities to discuss and receive support for deprescribing from a healthcare provider. We tested these mechanisms during theEliminating Medications through Patient Ownership of End Results (EMPOWER) () trial and investigated the contexts that led to positive and negative deprescribing outcomes. DESIGN A realist evaluation using a sequential mixed methods approach, conducted alongside the EMPOWER randomised clinical trial. SETTING Community, Quebec, Canada. PARTICIPANTS 261 older chronic benzodiazepine consumers, who received the EMPOWER intervention and had complete 6-month follow-up data. INTERVENTION Mailed deprescribing brochure on benzodiazepines. MEASUREMENTS Motivation (intent to discuss deprescribing; change in knowledge test score; change in beliefs about the risk-benefits of benzodiazepines, measured with the Beliefs about Medicines Questionnaire), capacity (self-efficacy for tapering) and opportunity (support from a physician or pharmacist). RESULTS The intervention triggered the motivation to deprescribe among 167 (n=64%) participants (mean age 74.6 years±6.3, 72% women), demonstrated by improved knowledge (risk difference, 58.50% (95% CI 46.98% to 67.44%)) and increased concern about taking benzodiazepines (risk difference, 67.67% (95% CI 57.36% to 74.91%)). Those who attempted to taper exhibited increased self-efficacy (risk difference, 56.90% (95% CI 45.41% to 65.77%)). Contexts where the deprescribing mechanisms failed included lack of support from a healthcare provider, a focus on short-term quality of life, intolerance to withdrawal symptoms and perceived poor health. CONCLUSION Deprescribing mechanisms that target patient motivation and capacity to deprescribe yield successful outcomes in contexts where healthcare providers are supportive, and patients do not have internal competing desires to remain on drug therapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01148186.
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Affiliation(s)
- Philippe Martin
- Faculty of Pharmacy, Université de Montréal, Montreal, Québec, Canada
- Institut Universitaire de Gériatrie de Montréal, Montreal, Québec, Canada
| | - Cara Tannenbaum
- Institut Universitaire de Gériatrie de Montréal, Montreal, Québec, Canada
- Université de Montréal, Faculties of Medicine and Pharmacy, Montreal, Québec, Canada
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