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Olender RT, Roy S, Jamieson HA, Hilmer SN, Nishtala PS. Drug Burden Index Is a Modifiable Predictor of 30-Day Hospitalization in Community-Dwelling Older Adults With Complex Care Needs: Machine Learning Analysis of InterRAI Data. J Gerontol A Biol Sci Med Sci 2024; 79:glae130. [PMID: 38733108 PMCID: PMC11215698 DOI: 10.1093/gerona/glae130] [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: 02/27/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Older adults (≥65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimize ML models further. Accurately predicting hospitalization may tremendously affect the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient. METHODS In this retrospective cohort study, a data set of 14 198 community-dwelling older adults (≥65 years) with complex care needs from the International Resident Assessment Instrument-Home Care database was used to develop and optimize 3 ML models to predict 30-day hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all 3 models to identify key predictors of 30-day hospitalization. RESULTS The area under the receiver-operating characteristics curve for the RF, XGB, and LR models were 0.97, 0.90, and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day hospitalization. CONCLUSIONS Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.
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Affiliation(s)
| | - Sandipan Roy
- Department of Mathematical Sciences, University of Bath, Bath, UK
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sarah N Hilmer
- Faculty of Medicine and Health, Kolling Institute, Northern Clinical School, The University of Sydney and Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Prasad S Nishtala
- Department of Life Sciences & Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Liu BM, Redston MR, Fujita K, Thillainadesan J, Gnjidic D, Hilmer SN. The Impact of Deprescribing Interventions on the Drug Burden Index and Other Outcomes: A Systematic Review. J Am Med Dir Assoc 2024; 25:105021. [PMID: 38763161 DOI: 10.1016/j.jamda.2024.105021] [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: 02/11/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVES The Drug Burden Index (DBI) calculates a person's exposure to anticholinergic and sedative medications. We aimed to review randomized controlled trials (RCTs) of deprescribing interventions that reported the DBI as an outcome, their characteristics, effectiveness in reducing the DBI, and impact on other outcomes. DESIGN Systematic review with meta-analysis. SETTING AND PARTICIPANTS RCTs of deprescribing interventions where the DBI was measured as a primary or secondary outcome in humans within any setting were included. METHODS Electronic databases, citation indexes, and gray literature were searched from April 1, 2007, to September 1, 2023. Quality was assessed using the Cochrane risk-of-bias tool. RESULTS Of 1721 records identified, 9 met the inclusion criteria. Six interventions were delivered by pharmacists and 3 were delivered by pharmacists/nurses or pharmacists/geriatricians. All interventions required at least intermediate-level skills and involved multiple components and target groups. Studies were conducted in the community (n = 5), nursing homes (n = 2), and hospitals (n = 2). The mean or median age was ≥75 years and most participants were women in all studies. Most (n = 6) studies were underpowered. The follow-up period ranged from 3 to 12 months. Three studies reported a lower DBI in the intervention group compared with control: 1 pharmacist independent prescriber-delivered in nursing homes (adjusted rate ratio, 0.83; 95% CI, 0.74 to 0.92), 1 pharmacist/nurse practitioner-delivered in hospital (adjusted mean difference (MD), -0.28; 95% CI, -0.51 to -0.04), and 1 geriatrician/pharmacist-delivered in hospital (MD, -0.28; 95% CI, -0.52 to -0.04). Meta-analysis showed no difference in the change in DBI between control and intervention groups in the community including nursing homes (MD, -0.03; 95% CI, -0.08 to 0.01) or hospital setting (MD, -0.19; 95% CI, -0.45 to 0.06). Interventions had inconsistent effects on cognition and no effect on other reported outcomes. CONCLUSIONS AND IMPLICATIONS RCTs of deprescribing interventions had no significant impact on reducing DBI or improving outcomes. Further suitably powered studies are required.
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Affiliation(s)
- Bonnie M Liu
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia; Aged Care Department, Royal North Shore Hospital, Sydney, Australia.
| | - Mitchell R Redston
- St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kenji Fujita
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia
| | - Janani Thillainadesan
- Department of Geriatric Medicine and Centre for Education and Research on Ageing, Concord Hospital, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah N Hilmer
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia; Aged Care Department, Royal North Shore Hospital, Sydney, Australia; Clinical Pharmacology Department, Royal North Shore Hospital, Sydney, Australia
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Truong M, Van C, Sud K, Tesfaye W, Croker N, Seth S, Castelino RL. Drug-Related Problems and Recommendations Made during Home Medicines Reviews for Sick Day Medication Management in Australia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:798. [PMID: 38792982 PMCID: PMC11123247 DOI: 10.3390/medicina60050798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024]
Abstract
Backgrounds and Objectives: Using certain medications during an intercurrent illness can increase the risk of drug related problems (DRP) occurring such as acute kidney injury (AKI). Medications that increase this risk include sulfonylureas, angiotensin converting enzyme inhibitors, diuretics, metformin, angiotensin receptor blockers, non-steroidal anti-inflammatories drugs, and sodium glucose co-transporter 2 inhibitors (SADMANS). Sick day medication guidance (SDMG) recommends withholding SADMANS medications during an intercurrent illness where adequate fluid intake cannot be maintained. But uptake of these recommendations is poor, and it is not known whether Australian pharmacists currently provide these recommendations during home medicine reviews (HMR) as per SDMG. We aimed to gain an understanding of the characteristics of DRP identified by pharmacists during HMR, especially those relating to SADMANS medications. Materials and Methods: We conducted a retrospective audit of 201 randomly selected HMR reports, conducted by accredited pharmacists from 2020 to 2022, that were analysed in 2023. All DRP and recommendations were categorised using a modified DOCUMENT system. Results: Overall, over 98% of participants experienced a DRP and a total of 710 DRP were found, where participants experienced an average of 4.0 ± 2.0 DRP each. Non-SADMANS medications accounted for 83.1% of all DRPs, with nervous system medications contributing the most. Common problems seen in non-SADMANS medications were related to toxicity, over/underdosing and undertreating. Diuretics contributed most to DRP in SADMANS medications. Problems with SADMANS were mainly related to toxicity and contraindications. No pharmacists provided SDMG despite 71.1% of participants using at least one SADMANS medication. Conclusions: We conclude that DRP remain prevalent in community pharmacy settings. Sick day recommendations were not provided in the HMRs included in our study, possibly due to lack of pharmacist knowledge and awareness. To ensure best practice, more research should be conducted to determine pharmacists' knowledge of and barriers to provision of sick day recommendations.
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Affiliation(s)
- Mimi Truong
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - Connie Van
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - Kamal Sud
- Nepean Kidney Research Centre, Department of Renal Medicine, Nepean Hospital, Nepean and Blue Mountains Local Health District, Kingswood 2747, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - Wubshet Tesfaye
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane 4072, Australia
| | | | - Shrey Seth
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - Ronald Lynel Castelino
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown 2148, Australia
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Sawan MJ, Clough A, Hillen J, Soulsby N, Gnjidic D. Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews. Australas J Ageing 2024. [PMID: 38581686 DOI: 10.1111/ajag.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/19/2023] [Accepted: 03/15/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVES Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR. METHODS A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia. RESULTS Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001). CONCLUSIONS In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.
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Affiliation(s)
- Mouna J Sawan
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexander Clough
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jodie Hillen
- University of South Australia, Adelaide, South Australia, Australia
- Ward Medication Management, Melbourne, Victoria, Australia
| | | | - Danijela Gnjidic
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
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Truong M, Tesfaye W, Sud K, Van C, Seth S, Croker N, Castelino RL. Drug-Related Problems and Sick Day Management Considerations for Medications that Contribute to the Risk of Acute Kidney Injury. J Clin Med 2024; 13:343. [PMID: 38256477 PMCID: PMC10816903 DOI: 10.3390/jcm13020343] [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: 11/28/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Medication use during acute illness increases the risk of experiencing drug related problems (DRPs), including acute kidney injuries. It is recommended that potentially nephrotoxic medications are withheld during acute illness, including sulfonylureas, angiotensin converting enzyme inhibitors, diuretics, metformin, angiotensin receptor blockers, non-steroidal anti-inflammatories and sodium glucose co-transporter 2 inhibitors (SADMANS). It is unknown if Australian pharmacists currently provide sick day medication management advice regarding SADMANS medications. Hence, we aimed to identify current DRPs and the recommendations made during residential medication management reviews (RMMRs), especially with SADMANS medications. METHODS A retrospective review of 408 RMMRs was conducted. DRPs and pharmacist recommendations were classified according to a modified DOCUMENT system. General practitioners' (GP) recommendations were also categorised. RESULTS Over 97% of residents experienced at least one DRP. Common problems for non-SADMANS medications were "toxicity or adverse drug reaction", "drug selection" and "over/underdosing" and those for SADMANS medications included "toxicity or adverse drug reaction", "monitoring" and "drug selection". GPs agreed with pharmacist recommendations approximately 40% of the time. No pharmacists provided sick day medication management advice for SADMANS medications. CONCLUSION DRPs remain highly prevalent in aged care facilities. Medication reviews effectively identify and resolve DRPs approximately 40% of the time, but do not currently minimise the risk associated with using SADMANS medications during sick days, which is a potential area of improvement.
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Affiliation(s)
- Mimi Truong
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (W.T.); (C.V.); (R.L.C.)
| | - Wubshet Tesfaye
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (W.T.); (C.V.); (R.L.C.)
| | - Kamal Sud
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Nepean Kidney Research Centre, Department of Renal Medicine, Nepean Hospital, Nepean and Blue Mountains Local Health District, Kingswood 2747, Australia
| | - Connie Van
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (W.T.); (C.V.); (R.L.C.)
| | - Shrey Seth
- Manipal Academy of Higher Education (MAHE), The University of Sydney, Sydney 2006, Australia
| | | | - Ronald Lynel Castelino
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia; (W.T.); (C.V.); (R.L.C.)
- Pharmacy Department, Blacktown Hospital, WSLHD, Blacktown 2148, Australia
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Katipoglu B, Kurtbeyoglu S, Demir ZA, Mavioglu HL. The effect of the anticholinergic burden on mortality following elective cardiac surgery. Curr Med Res Opin 2024; 40:27-34. [PMID: 37999982 DOI: 10.1080/03007995.2023.2288278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 11/22/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients. METHODS This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records. RESULTS A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10-1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27-3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively). CONCLUSION The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period. TRIAL REGISTRATION The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.
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Affiliation(s)
- Bilal Katipoglu
- Balikesir Atatürk City Hospital, Division of Geriatrics, Balikesir, Turkiye
| | - Seda Kurtbeyoglu
- Anesthesiology and Reanimation Department, Ankara City Hospital, Ankara, Turkiye
| | - Zeliha Asli Demir
- Anesthesiology and Reanimation Department, Ankara City Hospital, University of Health Sciences, Ankara, Turkiye
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Healy D. The past, present and future of anticholinergic drugs. Ther Adv Psychopharmacol 2023; 13:20451253231176375. [PMID: 37701889 PMCID: PMC10493060 DOI: 10.1177/20451253231176375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/28/2023] [Indexed: 09/14/2023] Open
Abstract
In current medical practice, it is difficult to find any reports claiming that drugs that are primarily anticholinergic or those that have significant anticholinergic effects have any therapeutic benefits. These drugs fell into disrepute within the mental health field from the mid-1960s onwards, and their supposed problems extended to elsewhere in medicine after that. There is considerable evidence that this disrepute stemmed more from marketing copy rather than from hard clinical trial data. Many apparent reviews appear to repeat prior claims rather than present substantial or new evidence. This article offers a perspective rather than a systematic review as there is little evidence other than claims to review. The aim is to challenge the conventional narrative that anticholinergic effects are uniquely hazardous by pointing to the uncertain basis for claims about the harms of anticholinergic drugs, antimuscarinic drugs in particular, ending with pointers to recent research that, if realized, might underpin important possible future benefits.
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Affiliation(s)
- David Healy
- Data Based Medicine Americas Ltd., 95 Sandringham Drive, Toronto, ON, M3H 1E1 Canada
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Moles RJ, Perry L, Naylor JM, Center J, Ebeling P, Duque G, Major G, White C, Yates C, Jennings M, Kotowicz M, Tran T, Bliuc D, Si L, Gibson K, Basger BJ, Bolton P, Barnett S, Hassett G, Kelly A, Bazarnik B, Ezz W, Luckie K, Carter SR. Safer medicines To reduce falls and refractures for OsteoPorosis (#STOP): a study protocol for a randomised controlled trial of medical specialist-initiated pharmacist-led medication management reviews in primary care. BMJ Open 2023; 13:e072050. [PMID: 37620274 PMCID: PMC10450068 DOI: 10.1136/bmjopen-2023-072050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF. METHOD AND ANALYSIS Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care. ETHICS AND DISSEMINATION Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up. TRIAL REGISTRATION NUMBER ACTRN12622000261718.
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Affiliation(s)
- Rebekah Jane Moles
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lin Perry
- School of Nursing and Midwifery, University of Technology Sydney Faculty of Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Southwestern Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline Center
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Peter Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Gustavo Duque
- Australian Institute for Musculoskeletal Science, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor Major
- Department of Rheumatology, Bone and Joint Centre, Royal Newcastle Centre, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Christopher White
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Christopher Yates
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Matthew Jennings
- Physiotherapy, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Mark Kotowicz
- Epi-Centre for Healthy Ageing, Deakin University - Geelong Campus at Waurn Ponds, Geelong, Victoria, Australia
- Barwon Health, Geelong, Victoria, Australia
| | - Thach Tran
- Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Dana Bliuc
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Lei Si
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Kathryn Gibson
- Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Benjamin Joseph Basger
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Patrick Bolton
- Public Health and Community Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Stephen Barnett
- GP Academic Unit, University of Wollongong, Wollongong, New South Wales, Australia
| | - Geraldine Hassett
- Ingham Institute, Liverpool, New South Wales, Australia
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ayano Kelly
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Barbara Bazarnik
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Wafaa Ezz
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate Luckie
- Musculoskeletal Clinical Group, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Ross Carter
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Fujita K, Hooper P, Masnoon N, Lo S, Gnjidic D, Etherton-Beer C, Reeve E, Magin P, Bell JS, Rockwood K, O'Donnell LK, Sawan M, Baysari M, Hilmer SN. Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study. Drugs Aging 2023:10.1007/s40266-023-01032-6. [PMID: 37160561 DOI: 10.1007/s40266-023-01032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing. OBJECTIVE The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation. METHODS This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications. RESULTS Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04). CONCLUSION Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.
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Affiliation(s)
- Kenji Fujita
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Patrick Hooper
- eMR Connect Program, eHealth NSW, Sydney, NSW, Australia
| | - Nashwa Masnoon
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Sarita Lo
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Parker Magin
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Kenneth Rockwood
- Department of Medicine (Geriatric Medicine & Neurology), Dalhousie University; Frailty and Elder Care Network, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Mouna Sawan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, NSW, Australia.
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10
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Alshammari MK, Alotaibi NM, Al Suroor SN, Al Saed RS, Al-Hamoud AA, Alluwaif MA, Alamry MA, Alshehri NM, Alfaidi BE, Alzahrani RA, Almutiri BB, Alosaimi YS, Alosman AS, Alharbi AA, Alenezi AM. Global Advancement in Pharmacy Services for Mental Health: A Review for Evidence-Based Practices. Healthcare (Basel) 2023; 11:healthcare11081082. [PMID: 37107916 PMCID: PMC10137606 DOI: 10.3390/healthcare11081082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
The symptoms of psychiatric infirmities have variability, and selected drug regimens for mental illness are comparatively complex and individualized; therefore, pharmacy services vary with respect to patients, diseases, healthcare settings, community structures, and countries. Clinical pharmacy services for mental health (MH) are continuously being upgraded. A structured search of the literature was performed in the Cochrane, PubMed (Medline), PsycINFO, Google scholar, Scopus, Science Direct, and Springer Links databases. The title and abstract of each retrieved article were evaluated for relevance. To remove uncertainty and ambiguity, the full-text articles were retrieved and examined for relevance. The articles were further assessed on the basis of inclusion and exclusion criteria. Narrative synthesis was performed, creating new categories and relevant subcategories and further subsections. The articles and the results were assessed for quality and bias. Pharmacists have a range of expertise in psychiatric care. The services can be classified as conventional, extended, and advanced pharmacy services. Conventional services include the quality use of medicines in healthcare settings and medication support services in communities that ensure medication adherence. Pharmacists perform extended roles in collaborative medication therapy management, multidisciplinary community mental health teams, collaborative care, patient education, home medication review, hospital-to-home transit, and screening services. In the USA, the role of pharmacists was advanced by prescribing as collaborative and interim prescribers. Australia launched an accredited program for psychiatric first-aid pharmacists. Pharmacists can provide mental care to rural populations using health technology. The role of pharmacists in MH is appreciated either independently or as a team member. Patients and healthcare providers rank the services of pharmacists in MH highly. Still, there is a margin for improvement in the training of pharmacists. Pharmacists cannot provide sufficient time to their patients. Public awareness about the role of pharmacists in MH needs more attention. Moreover, the training of psychiatric pharmacists should be standardized around the world.
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Affiliation(s)
| | - Nawaf M Alotaibi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Northern Border University, Rafha 73213, Saudi Arabia
| | | | - Rami Saleh Al Saed
- Department of Pharmacy, Maternity and Children Hospital Dammam, Dammam 63400, Saudi Arabia
| | - Aliaa Ali Al-Hamoud
- Department of Pharmacy, Maternity and Children Hospital Dammam, Dammam 63400, Saudi Arabia
| | - Mawahb Ahmed Alluwaif
- Department of Pharmacy, Maternity and Children Hospital Dammam, Dammam 63400, Saudi Arabia
| | - Mona Awadh Alamry
- Department of Pharmacy, Khamis Mushait General Hospital, Khamis Mushait 62441, Saudi Arabia
| | | | - Bashaier Eed Alfaidi
- Department of Pharmacy, Umluj General Hospital, Ministry of Health, Northern Region, Umluj City 48312, Saudi Arabia
| | | | | | - Yousef Saud Alosaimi
- Department of Pharmacy, Dr. Sulaiman Al Habib Hospital, Riyadh 14926, Saudi Arabia
| | - Amal Saeed Alosman
- Department of Pharmacy, King Khalid University, South Zone, Abha 62541, Saudi Arabia
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11
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Quek HW, Etherton-Beer C, Page A, McLachlan AJ, Lo SY, Naganathan V, Kearney L, Hilmer SN, Comans T, Mangin D, Lindley RI, Potter K. Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation. Arch Gerontol Geriatr 2023; 107:104910. [PMID: 36565605 DOI: 10.1016/j.archger.2022.104910] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/07/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation. OBJECTIVES This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month. METHODS The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner. RESULTS There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231). CONCLUSION Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613001204730.
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Affiliation(s)
- Hui Wen Quek
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; School of Allied Health, University of Western Australia, Perth, Western Australia, Australia.
| | - Christopher Etherton-Beer
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Amy Page
- School of Allied Health, University of Western Australia, Perth, Western Australia, Australia; Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sarita Y Lo
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Kolling Institute, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Leanne Kearney
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sarah N Hilmer
- Kolling Institute, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tracy Comans
- Menzies Health Institute Queensland, Griffith University, University Drive Meadowbrook, Brisbane, Queensland Australia
| | - Derelie Mangin
- Primary Care Research Unit, Department of Public Health and General Practice, Christchurch School of Medicine & Health Sciences, University of Otago, Christchurch, New Zealand
| | - Richard I Lindley
- Sydney Medical School, University of Sydney, Sydney, New South Wales; Australia and The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kathleen Potter
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia; Ryman Healthcare, Christchurch, New Zealand
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12
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Katzenberger B, Koller D, Strobl R, Kisch R, Sanftenberg L, Voigt K, Grill E. Exposure to anticholinergic and sedative medication is associated with impaired functioning in older people with vertigo, dizziness and balance disorders-Results from the longitudinal multicenter study MobilE-TRA. Front Pharmacol 2023; 14:1136757. [PMID: 36937862 PMCID: PMC10020174 DOI: 10.3389/fphar.2023.1136757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction: Anticholinergic and sedative medication is prescribed for various conditions in older patients. While the general association between anticholinergic and sedative medication and impaired functioning is well established, its specific role in older individuals with vertigo, dizziness, and balance disorders (VDB) is still incompletely understood. The objective of this study was to investigate, whether an exposure to anticholinergic and sedative medication is associated with lower generic and lower vertigo-specific functioning in older patients with VDB. Methods: Data originates from the longitudinal multicenter study MobilE-TRA with two follow-ups, conducted from 2017 to 2019 in two German federal states. Exposure to anticholinergic and sedative medication was quantified using the drug burden index (DBI). Generic functioning was assessed by the Health Assessment Questionnaire Disability Index, appraising the amount of difficulties in performing activities of daily living (ADL). Vertigo-specific functioning was measured using the Vestibular Activities and Participation (VAP) questionnaire, assessing patient-reported functioning regarding activities of daily living that are difficult to perform because of their propensity to provoke VDB (Scale 1) as well as immediate consequences of VDB on activities and participation related to mobility (Scale 2). Longitudinal linear mixed models were applied to assess the association of exposure to anticholinergic and sedative medication at baseline and the level of generic and vertigo-specific functioning status over time. Results: An overall of 19 (7 from Bavaria) primary care physicians (mean age = 54 years, 29% female) recruited 158 (59% from Bavaria) patients with VDB (median age = 78 years, 70% female). Anticholinergic and sedative medication at baseline was present in 56 (35%) patients. An exposure to anticholinergic and sedative medication at baseline was significantly associated with lower generic functioning [Beta = 0.40, 95%-CI (0.18; 0.61)] and lower vertigo-specific functioning [VAP Scale 1: Beta = 2.47, 95%-CI (0.92; 4.02)], and VAP Scale 2: Beta = 3.74, 95%-CI [2.23; 5.24]). Conclusion: Our results highlight the importance of a close monitoring of anticholinergic and sedative medication use in older patients with VDB. When feasible, anticholinergic and sedative medication should be replaced by equivalent alternative therapies in order to potentially reduce the burden of VDB.
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Affiliation(s)
- Benedict Katzenberger
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
- Munich Center of Health Sciences, Ludwig Maximilian University of Munich, Munich, Germany
- *Correspondence: Benedict Katzenberger,
| | - Daniela Koller
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- Munich Center of Health Sciences, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ralf Strobl
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Munich, Germany
| | - Rebecca Kisch
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
| | - Linda Sanftenberg
- Institute of General Practice and Family Medicine, University Hospital Munich, Munich, Germany
| | - Karen Voigt
- Department of General Practice/Medical Clinic III, Faculty of Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Munich, Germany
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13
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Basheti MM, Tran M, Wong K, Gordon C, Grunstein R, Saini B. Australian Consultant Pharmacists' Potential Roles in Sleep Health Care: Exploring a New Avenue for Improving the Management of Insomnia. Behav Sleep Med 2022; 20:622-637. [PMID: 34520308 DOI: 10.1080/15402002.2021.1975718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The first-line treatment for insomnia is cognitive-behavioral therapy. However, there is persistent use of pharmacotherapy, particularly, sedative-hypnotics. Consultant pharmacists can provide medication review services for people using multiple medications. Therefore, they are well placed to provide sleep health/insomnia care with regard to sedative-hypnotic use and behavioral treatment recommendations/sleep health education. However, this avenue is, as yet, unexplored. OBJECTIVES To explore consultant pharmacists' current sleep health-related provisions and what their perspectives are around developing/implementing a consultant pharmacist-led behavioral service for insomnia. METHODS Qualitative semi-structured interviews were conducted with a convenience-based sample of consultant pharmacists. Interviews were audio-recorded, transcribed, and inductively analyzed. RESULTS Twenty-four consultant pharmacists were interviewed. Three themes were gauged: 1) Trivializing insomnia and sleep health, 2) Providing patient-centered care, 3) Service implementation - What do we need to consider? Participants commonly dealt with older patients and frequently encountered patients with sleep complaints/taking sleep medications. Generally, it was believed that sleep health was given minimal priority, with other comorbidities taking precedence in health provisions. Patients' attitudes toward management approaches were regarded critical to future treatment developments. While interested in expanding their sleep health/insomnia practice, participants expressed the need for appropriate education/training, funding, and collaborative treatment frameworks. CONCLUSION Insomnia/sleep health concerns are growing. Primary health professionals need to scale up their sleep health-care provisions to accommodate for this health demand. Consultant pharmacists are interested/willing to expand their sleep-related practice and provide evidence-based insomnia therapies; however, factors such as education/training, service configuration support, and patient attitudes should be addressed.
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Affiliation(s)
- Mariam M Basheti
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Cirus, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Minh Tran
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Australian Association of Consultant Pharmacy, Australia
| | - Keith Wong
- Cirus, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia.,School of Medicine, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.,Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Christopher Gordon
- Cirus, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia.,Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Ronald Grunstein
- Cirus, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia.,School of Medicine, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.,Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bandana Saini
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Cirus, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia
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14
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Sluggett JK, Caughey GE, Air T, Moldovan M, Lang C, Martin G, Carter SR, Jackson S, Stafford AC, Wesselingh SL, Inacio MC. Medicines use before and after comprehensive medicines review among residents of long-term care facilities: a retrospective cohort study. BMC Geriatr 2022; 22:493. [PMID: 35676644 PMCID: PMC9178815 DOI: 10.1186/s12877-022-03187-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 05/25/2022] [Indexed: 12/18/2022] Open
Abstract
Background Residential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR. Methods This retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes. Results 113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3–6 and 6–12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6–12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR. Conclusions For six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6–12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03187-0.
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Affiliation(s)
- Janet K Sluggett
- University of South Australia, UniSA Allied Health and Human Performance, GPO Box 2471, Adelaide, South Australia, Australia. .,Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia. .,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.
| | - Gillian E Caughey
- University of South Australia, UniSA Allied Health and Human Performance, GPO Box 2471, Adelaide, South Australia, Australia.,Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Tracy Air
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Max Moldovan
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Biometry Hub, Faculty of Sciences, Engineering and Technology, The University of Adelaide, Waite Campus, Urrbrae, South Australia, Australia
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Grant Martin
- Australian Association of Consultant Pharmacy, Australian Capital Territory, Fyshwick, Australia
| | - Stephen R Carter
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Shane Jackson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Andrew C Stafford
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Steve L Wesselingh
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Maria C Inacio
- University of South Australia, UniSA Allied Health and Human Performance, GPO Box 2471, Adelaide, South Australia, Australia.,Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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15
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Thiruchelvam K, Byles J, Hasan SS, Egan N, Kairuz T. Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care. Res Social Adm Pharm 2022; 18:3758-3765. [DOI: 10.1016/j.sapharm.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/04/2022] [Accepted: 05/07/2022] [Indexed: 12/01/2022]
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16
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Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review. J Clin Psychopharmacol 2022; 42:169-187. [PMID: 35230048 DOI: 10.1097/jcp.0000000000001521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps. METHODS We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively. RESULTS Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies. CONCLUSIONS Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.
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17
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Effectiveness of Interventions to Improve the Anticholinergic Prescribing Practice in Older Adults: A Systematic Review. J Clin Med 2022; 11:jcm11030714. [PMID: 35160166 PMCID: PMC8836376 DOI: 10.3390/jcm11030714] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pharmacotherapy in older adults is one of the most challenging aspects of patient care. Older people are prone to drug-related problems such as adverse effects, ineffectiveness, underdosage, overdosage, and drug interactions. Anticholinergic medications are associated with poor outcomes in older patients, and there is no specific intervention strategy for reducing drug burden from anticholinergic activity medications. Little is known about the effectiveness of current interventions that may likely improve the anticholinergic prescribing practice in older adults. AIMS This review seeks to document all types of interventions aiming to reduce anticholinergic prescribing among older adults and assess the current evidence and quality of existing single and combined interventions. METHODS We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO from January 1990 to August 2021. Only studies that examined the effect of interventions in older people focused on improving compliance with anticholinergic prescribing guidelines with quantifiable data were included. The primary outcome of interest was to find the effectiveness of interventions that enhance the anticholinergic prescribing practice in older adults. RESULTS We screened 3168 records and ended up in 23 studies that met the inclusion criteria. We found only single-component interventions to reduce anticholinergic prescribing errors in older people. Pharmacists implemented interventions without collaboration in nearly half of the studies (n = 11). Medication review (43%) and education provision (26%) to healthcare practitioners were the most common interventions. Sixteen studies (70%) reported significant reductions in anticholinergic prescribing errors, whereas seven studies (30%) showed no significant effect. CONCLUSION This systematic review suggests that healthcare practitioner-oriented interventions have the potential to reduce the occurrence of anticholinergic prescribing errors in older people. Interventions were primarily effective in reducing the burden of anticholinergic medications and assisting with deprescribing anticholinergic medications in older adults.
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18
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Okoro RN, Idris AI. Older adults’ exposure to anticholinergic medications: Implications for pharmaceutical care for Nigerian older adults. THE JOURNAL OF MEDICINE ACCESS 2022; 6:27550834221112753. [PMID: 36204529 PMCID: PMC9483949 DOI: 10.1177/27550834221112753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/22/2022] [Indexed: 11/15/2022]
Abstract
Introduction: Anticholinergic medications which are commonly prescribed to older adults can
produce more pronounced adverse effects compared to the younger
population. Objectives: To investigate the prevalence of polypharmacy, describe the prescription
patterns of anticholinergic medications, determine the prevalence of
exposure to high-risk anticholinergic cognitive burden (ACB) medications,
and identify the potential predictors of exposure to high-risk ACB
medications in older adults in a Nigerian secondary hospital. Methods: This cross-sectional study that included older adults prescribed at least one
anticholinergic medication was conducted at a secondary care hospital in
Nigeria. The study data were initially summarized using descriptive
statistics, whereas multivariable logistic regression analysis was used to
identify the potential predictors of exposure to high-risk ACB medications.
In this study, the cumulative ACB scores were dichotomized into low risk
(score 1–2) and high risk (score ⩾ 3). A p value less than
0.05 was considered to be statistically significant. Results: A total of 256 older adults were included in this study; 113 (44.1%) had
polypharmacy, whereas 26.6% (188/256) were exposed to high-risk ACB
medications. Of a total of 391 anticholinergic medications used by the
population, furosemide (36.57%) was the most commonly prescribed. The
adjusted multivariable logistic regression analysis indicated that patients
who had acute diseases were 2.5 times (adjusted odds ratio (AOR) = 2.49, 95%
confidence interval (CI): 1.40–4.45) more likely to be exposed to high-risk
ACB medications than those with chronic diseases. Conclusion: The study demonstrates a high prevalence of polypharmacy and exposure to
high-risk ACB medications suggesting the need for pharmaceutical care in
this high-risk population. Older adults’ exposure to high-risk ACB
medications was significantly associated with prescriptions for acute
diseases.
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Affiliation(s)
- Roland Nnaemeka Okoro
- Department of Clinical Pharmacy and Pharmacy Administration, University of Maiduguri, Maiduguri, Nigeria
| | - Algoni Idris Idris
- Department of Clinical Pharmacy and Pharmacy Administration, University of Maiduguri, Maiduguri, Nigeria
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19
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Birt L, Dalgarno L, Wright DJ, Alharthi M, Inch J, Spargo M, Blacklock J, Poland F, Holland RC, Alldred DP, Hughes CM, Bond CM. Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS). BMC Health Serv Res 2021; 21:1041. [PMID: 34600542 PMCID: PMC8487235 DOI: 10.1186/s12913-021-07062-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation. Method Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework. Results PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention. Conclusions The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established. Trial registration The definitive RCT was registered with the ISRCTN registry (registration number ISRCTN 17847169). Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07062-3.
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Affiliation(s)
- Linda Birt
- The Queen's Building, School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Lindsay Dalgarno
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - David J Wright
- School of Pharmacy, University of East Anglia, Norwich, UK
| | | | - Jackie Inch
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Maureen Spargo
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Fiona Poland
- The Queen's Building, School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | | | - David P Alldred
- School of Healthcare, University of Leeds, Leeds, UK.,NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Leeds, UK
| | | | - Christine M Bond
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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20
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Gonçalves JR, Ramalhinho I, Sleath BL, Lopes MJ, Cavaco AM. Probing pharmacists' interventions in Long-Term Care: a systematic review. Eur Geriatr Med 2021; 12:673-693. [PMID: 33743169 DOI: 10.1007/s41999-021-00469-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Long-Term Care (LTC) systems have experienced recent developments driven by changes in healthcare and demography (e.g. population ageing). As well, pharmacists are changing from traditional roles to more patient-oriented services. The present study aimed to identify and assess pharmacists' and/or pharmacy-based interventions in institutional LTC settings, also mapping relevant medications. METHODS The review was undertaken in general accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), using three main literature databases (PubMed, Scopus, and Web of Knowledge). A set of 16 keywords, divided into three domains (professional, type of care and type of setting), were combined into search equations. Selected studies were assessed through the Quality Assessment Tool for Quantitative Studies. RESULTS Twenty-six studies met the inclusion criteria, out of 794 initial hits. Most studies (12) described pharmacist/pharmacy-driven interventions assessing Medication Management Reviews' impact in different endpoints or outcomes. Other studies (3) assessed pharmacists' interventions on specific medication groups. Good Administration Practices, new pharmaceutical care models, antibiotic stewardship programs, and studies assessing other pharmacists' interventions, such as pharmacy-managed informatics and education, were addressed by 11 other papers. Six studies were classified as Strong after quality assessment. CONCLUSION LTC is a clinically complex type of care benefiting from interdisciplinary work. Despite the overall lower quality of the identified studies, pharmacists perform in a wide array of LTC areas. The broad implementation of pharmaceutical activities in institutional LTC settings opens opportunities to optimise medicines' use.
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Affiliation(s)
- João R Gonçalves
- iMed.ULisboa, Social Pharmacy Department, Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, 1649-003, Lisboa, Portugal.
| | - Isabel Ramalhinho
- Faculty of Science and Technology, University of Algarve, Campus de Gambelas, 8005-139, Faro, Portugal
| | - Betsy L Sleath
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manuel J Lopes
- College of Nursing S. João de Deus, University of Évora, 7000-811, Évora, Portugal
| | - Afonso M Cavaco
- iMed.ULisboa, Social Pharmacy Department, Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, 1649-003, Lisboa, Portugal
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21
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Adie K, Fois RA, McLachlan AJ, Chen TF. Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study. Eur J Clin Pharmacol 2021; 77:1381-1395. [PMID: 33646375 DOI: 10.1007/s00228-020-03075-9] [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: 07/26/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To identify factors in community pharmacy that facilitate error recovery from medication incidents (MIs) and explore medication safety prevention strategies from the pharmacist perspective. METHODS Thirty community pharmacies in Sydney, Australia, participated in a 30-month prospective incident reporting program of MIs classified in the Advanced Incident Management System (AIMS) and the analysis triangulated with case studies. The main outcome measures were the relative frequencies and patterns in MI detection, minimisation, restorative actions and prevention recommendations of community pharmacists. RESULTS Participants reported 1013 incidents with 831 recovered near misses and 165 purported patient harm. MIs were mainly initiated at the prescribing (68.2%) and dispensing (22.6%) stages, and most were resolved at the pharmacy (76.9%). Detection was efficient within the first 24 h in 54.6% of MIs, but 26.1% required one month or longer; 37.2% occurred after the patient consumed the medicine. The combination of specific actions/attributes (85.5%), appropriate interventions (81.6%) and effective communication (77.7%) minimised MIs. An array of remedial actions were conducted by participants including notification, referral, advice, modification of medication regimen, risk management and documentation corrections. Recommended prevention strategies involved espousal of medication safety culture (97.8%), better application of policies/procedures (84.6%) and improvements in healthcare providers' education (79.9%). CONCLUSION Incident reporting provided insights on the human and organisational factors involved in the recovery of MIs in community pharmacy. Optimising existing safeguards and redesigning certain structures and processes may enhance the resilience of the medication use system in primary care.
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Affiliation(s)
- Khaled Adie
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
| | - Romano A Fois
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Timothy F Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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22
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Langford AV, Ngo GT, Chen TF, Roberts C, Schneider CR. Nurses', Pharmacists' and Family Physicians' Perceptions of Psychotropic Medication Monitoring in Australian Long-Term Care Facilities: A Qualitative Framework Analysis. Drugs Aging 2020; 38:169-179. [PMID: 33314009 DOI: 10.1007/s40266-020-00825-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current evidence suggests that despite modest benefit in using targeted psychotropic medications in the geriatric population, there is significant iatrogenic morbidity and mortality. Monitoring of the use of psychotropic medications by health care professionals (HCPs) to reduce adverse effects is often suboptimal; however, there have been few theoretically informed studies as to why this is so. OBJECTIVE This study aimed to elucidate facilitators and barriers to psychotropic medication monitoring in long-term care facilities (LTCFs) from the viewpoint of nurses, pharmacists and family physicians. Secondly, it intended to identify targets for tailored intervention strategies to improve monitoring practices. METHODS A purposive sample of 31 HCPs working in LTCFs in Sydney, New South Wales, Australia was recruited. Three cohorts consisted of twelve registered nurses, ten pharmacists and nine family physicians. Semi-structured interviews were conducted, assessing perceptions of psychotropic medication monitoring in LTCFs, facilitators, barriers and proposed solutions. Interviews were transcribed verbatim and thematically analyzed through an inductive coding approach. Themes were then mapped to Ferlie and Shortell's 'Four Levels of Change' framework for improving quality in healthcare. RESULTS Monitoring was revealed as a multi-faceted concept, influenced by factors across individual, group, organization and system levels. Thematic analysis revealed six key themes pertinent to psychotropic monitoring in LTCFs: (1) engagement with monitoring, (2) monitoring capability, (3) opportunity to monitor, (4) roles and responsibilities, (5) communication and collaboration and (6) guidance and regulation. HCPs conceptualized monitoring differently, but consistently felt that monitoring in LTCFs was suboptimal, recognizing a need for guidance and resources to aid collaborative monitoring of psychotropic medications. HCPs internally situated within LTCFs (nurses) viewed psychotropic medication monitoring as a dynamic and ongoing phenomenon, occurring both formally and informally on a day-to-day basis. In contrast, externally situated HCPs (pharmacists and family physicians) typically associated medication monitoring with structured medication reviews and conceptualized monitoring as an intermittent and planned activity. CONCLUSIONS AND IMPLICATIONS Psychotropic monitoring is perceived by all HCPs as a shared responsibility; however, the conceptualization of monitoring differs between HCPs. HCPs' beliefs and attitudes require consideration when designing implementation strategies for interventions to ameliorate suboptimal monitoring practices.
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Affiliation(s)
- Aili V Langford
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Garzee Tracy Ngo
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Chris Roberts
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Carl R Schneider
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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23
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Thapaliya K, Harris ML, Byles JE. Use of medication reviews among older women with dementia, 2003‐2015: A longitudinal cohort study. Australas J Ageing 2020; 39:e552-e558. [DOI: 10.1111/ajag.12836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Kailash Thapaliya
- Research Centre for Generational Health and Ageing University of Newcastle Newcastle NSW Australia
- Hunter Medical Research Institute (HMRI) Newcastle NSW Australia
| | - Melissa L. Harris
- Research Centre for Generational Health and Ageing University of Newcastle Newcastle NSW Australia
- Hunter Medical Research Institute (HMRI) Newcastle NSW Australia
| | - Julie E. Byles
- Research Centre for Generational Health and Ageing University of Newcastle Newcastle NSW Australia
- Hunter Medical Research Institute (HMRI) Newcastle NSW Australia
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24
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Chen TF, Sawan M. Psychotropic Medicine Stewardship: A Critical Role for Pharmacists in Long-Term Care Facilities. Sr Care Pharm 2020; 35:195-197. [PMID: 32340655 DOI: 10.4140/tcp.n.2020.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There are many opportunities for pharmacists to contribute to the better use of anxiolytic and sedative-hypnotic drugs, typically overprescribed and maintained for longer than recommended. Our research group has conducted a series of in-depth qualitative analyses that have deepened our understanding of the impact of organizational culture in long-term care facilities on the use of psychotropic medications.
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25
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Morcos M, Corns J, Hillen JB. Pharmacist-Initiated Management of a Suspected Case of Risperidone-Induced Neuroleptic Malignant Syndrome in an Aged-Care Resident. The Role of Residential Medication Management Reviews in Medication Safety. J Pharm Pract 2020; 33:382-385. [DOI: 10.1177/0897190018806414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 70-year-old female aged-care resident was referred by her general practitioner for a residential medication management review after nurses reported difficulties with swallowing, episodes of hyperthermia, elevated blood pressure, and tachycardia. These symptoms were accompanied by increasing confusion and drowsiness. Risperidone had recently been prescribed to treat behavioral and psychological symptoms of dementia. This case study describes the pharmacist-initiated management of the symptoms through a national medication review program. It demonstrates the valuable role collaborative medication reviews play in managing adverse drug reactions in aged-care.
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26
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O’Dwyer M, McCallion P, McCarron M, O’Connell J, Henman M. Measuring drug burden in older adults with intellectual disabilities: Critical issues for consideration in finding the optimal measure to improve safety of medicines use. Expert Opin Drug Saf 2020; 19:649-652. [DOI: 10.1080/14740338.2020.1751119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Maire O’Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
| | | | - Mary McCarron
- Trinity Centre for Ageing and Intellectual Disability, School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland
| | - Juliette O’Connell
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, Dublin 2, Ireland
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27
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Rasu RS, Agbor-Bawa W, Rianon NJ. Greater Changes in Drug Burden Index (DBI) during Hospitalization and Increased 30-Day Readmission Rates among Older In-Hospital Fallers. Hosp Top 2020; 98:59-67. [PMID: 32543345 DOI: 10.1080/00185868.2020.1777916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A higher drug burden index (DBI) is known to be associated with pre-admission falls leading to hospitalization. We investigated whether a mean difference in DBI (ΔDBI) between the events of in-hospital falls and hospital admission was associated with 30-day readmission in 113 patients ≥50 years who fell during their hospital stays between 2007 and 2014. A greater ΔDBI (≥0.09) was positively associated with higher 30-day readmission rates (incident rate ratio: 2.02; 95% confidence interval: 1.49-2.74). An effort to keep DBI low may thus decrease 30-day readmissions for older in-hospital fallers.
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Affiliation(s)
- Rafia S Rasu
- aDepartment of Pharmacotherapy, System College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Walter Agbor-Bawa
- aDepartment of Pharmacotherapy, System College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Nahid J Rianon
- bDivision of Geriatric and Palliative Medicin, Department of Internal Medicine, UTHealth McGovern Medical School, Houston, TX, USA
- Department of Family Medicine, UT Health McGovern Medical School, Houston, TX, USA
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28
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Maidment ID, Barton G, Campbell N, Shaw R, Seare N, Fox C, Iliffe S, Randle E, Hilton A, Brown G, Barnes N, Wilcock J, Gillespie S, Damery S. MEDREV (pharmacy-health psychology intervention in people living with dementia with behaviour that challenges): the feasibility of measuring clinical outcomes and costs of the intervention. BMC Health Serv Res 2020; 20:157. [PMID: 32122341 PMCID: PMC7053151 DOI: 10.1186/s12913-020-5014-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background People living with dementia in care homes frequently exhibit “behaviour that challenges”. Anti-psychotics are used to treat such behaviour, but are associated with significant morbidity. This study researched the feasibility of conducting a trial of a full clinical medication review for care home residents with behaviour that challenges, combined with staff training. This paper focusses on the feasibility of measuring clinical outcomes and intervention costs. Methods People living with moderate to severe dementia, receiving psychotropics for behaviour that challenges, in care homes were recruited for a medication review by a specialist pharmacist. Care home and primary care staff received training on the management of challenging behaviour. Data were collected at 8 weeks, and 3 and 6 months. Measures were Neuropsychiatric Inventory-Nursing Home version (NPI-NH), cognition (sMMSE), quality of life (EQ-5D-5 L/DEMQoL) and costs (Client Services Receipt Inventory). Response rates, for clinical, quality of life and health economic measures, including the levels of resource-use associated with the medication review and other non-intervention costs were calculated. Results Twenty-nine of 34 participants recruited received a medication review. It was feasible to measure the effects of the complex intervention on the management of behaviour that challenges with the NPI-NH. There was valid NPI-NH data at each time point (response rate = 100%). The sMMSE response rate was 18.2%. Levels of resource-use associated with the medication review were estimated for all 29 participants who received a medication review. Good response levels were achieved for other non-intervention costs (100% completion rate), and the EQ-5D-5 L and DEMQoL (≥88% at each of the time points where data was collected). Conclusions It is feasible to measure the clinical and cost effectiveness of a complex intervention for behaviour that challenges using the NPI-NH and quality of life measures. Trial registration ISRCTN58330068. Retrospectively registered, 15 October 2017.
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Affiliation(s)
- Ian D Maidment
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK.
| | - Garry Barton
- Norwich Clinical Trials Unit, University of East Anglia, Earlham Road, Norwich, Norfolk, NR4 7TJ, UK
| | - Niyah Campbell
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Rachel Shaw
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Nichola Seare
- Aston Health Research Innovation Cluster, Aston University, Birmingham, B4 7ET, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Earlham Road, Norwich, Norfolk, NR4 7TJ, UK
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF, UK
| | - Emma Randle
- Birmingham and Solihull Mental Health NHS Foundation Trust, Research and Innovation Department, The Barberry, 25 Vincent Drive, Birmingham, B15 2FG, UK
| | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, HU6 7RX, UK
| | - Graeme Brown
- Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB, UK
| | - Nigel Barnes
- Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF, UK
| | - Sarah Gillespie
- Department of Clinical Healthcare, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0FL, UK
| | - Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M, Gnjidic D. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol 2020; 13:233-245. [PMID: 32056451 DOI: 10.1080/17512433.2020.1730812] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.
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Affiliation(s)
- Mouna Sawan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, St Leonards, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Justin Turner
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, Australia
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30
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Dearing ME, Bowles S, Isenor J, Kits O, Kouladjian O'Donnell L, Neville H, Hilmer S, Toombs K, Sirois C, Hajizadeh M, Negus A, Rockwood K, Reeve E. Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis. BMJ Open 2020; 10:e035656. [PMID: 32086361 PMCID: PMC7044900 DOI: 10.1136/bmjopen-2019-035656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER NCT03698487.
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Affiliation(s)
- Marci Elizabeth Dearing
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan Bowles
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Olga Kits
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Kent Toombs
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Universite Laval, Québec city, Quebec, Canada
- Centre for Excellence on Aging of Quebec, Quebec Integrated University Centre for Health and Social Services of the National Capital, Québec city, Québec, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aprill Negus
- Department of Family Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Centre for Health Care of the Elderly, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Emily Reeve
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality Use of Medicines Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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31
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Harrison SL, Sluggett JK, Lang C, Whitehead C, Crotty M, Corlis M, Wesselingh SL, Inacio MC. The dispensing of psychotropic medicines to older people before and after they enter residential aged care. Med J Aust 2020; 212:309-313. [PMID: 32045014 DOI: 10.5694/mja2.50501] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care. DESIGN Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data. SETTING, PARTICIPANTS All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015. MAIN OUTCOME MEASURES Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter. RESULTS Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1-21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4-30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8-38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31-3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04-1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99-1.02). CONCLUSIONS Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care.
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Affiliation(s)
- Stephanie L Harrison
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Janet K Sluggett
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA.,Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA
| | - Craig Whitehead
- Southern Adelaide Local Health Network, SA Health, Adelaide, SA
| | | | | | | | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA.,Sansom Institute for Health Research, University of South Australia, Adelaide, SA
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Lee SWH, Mak VSL, Tang YW. Pharmacist services in nursing homes: A systematic review and meta-analysis. Br J Clin Pharmacol 2019; 85:2668-2688. [PMID: 31465121 DOI: 10.1111/bcp.14101] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/02/2019] [Accepted: 08/13/2019] [Indexed: 11/28/2022] Open
Abstract
AIMS Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown. METHODS Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes. RESULTS Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers. CONCLUSION Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.
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Affiliation(s)
- Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Subang Jaya, Selangor, Malaysia.,Gerentology Laboratory, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia.,School of Pharmacy, Taylor's University Lakeside Campus, Jalan Taylors, Subang Jaya, Selangor, Malaysia
| | - Vivienne Sook Li Mak
- Center of Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Yee Woon Tang
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Subang Jaya, Selangor, Malaysia
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Chen EYH, Wang KN, Sluggett JK, Ilomäki J, Hilmer SN, Corlis M, Bell JS. Process, impact and outcomes of medication review in Australian residential aged care facilities: A systematic review. Australas J Ageing 2019; 38 Suppl 2:9-25. [DOI: 10.1111/ajag.12676] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/28/2019] [Accepted: 04/30/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Esa Y. H. Chen
- Centre for Medicine Use and SafetyFaculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria Australia
- NHMRC Cognitive Decline Partnership CentreUniversity of Sydney Sydney New South Wales Australia
| | - Kate N. Wang
- Centre for Medicine Use and SafetyFaculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria Australia
| | - Janet K. Sluggett
- Centre for Medicine Use and SafetyFaculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria Australia
- NHMRC Cognitive Decline Partnership CentreUniversity of Sydney Sydney New South Wales Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and SafetyFaculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria Australia
- Department of Epidemiology and Preventive MedicineSchool of Public Health and Preventative MedicineMonash University Melbourne Victoria Australia
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership CentreUniversity of Sydney Sydney New South Wales Australia
- Kolling InstituteFaculty of Medicine and HealthThe University of Sydney and Royal North Shore Hospital St Leonards NSW Australia
| | - Megan Corlis
- NHMRC Cognitive Decline Partnership CentreUniversity of Sydney Sydney New South Wales Australia
- Helping Hand Aged Care North Adelaide South Australia Australia
| | - J. Simon Bell
- Centre for Medicine Use and SafetyFaculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria Australia
- NHMRC Cognitive Decline Partnership CentreUniversity of Sydney Sydney New South Wales Australia
- Department of Epidemiology and Preventive MedicineSchool of Public Health and Preventative MedicineMonash University Melbourne Victoria Australia
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Shafiee Hanjani L, Peel NM, Freeman CR, Gray LC. Using telehealth to enable collaboration of pharmacists and geriatricians in residential medication management reviews. Int J Clin Pharm 2019; 41:1256-1261. [PMID: 31401711 DOI: 10.1007/s11096-019-00890-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/02/2019] [Indexed: 11/25/2022]
Abstract
Background Practical issues impede optimum collaboration between pharmacists and other clinical specialists in the current Australian residential medication review services which potentially affect efficiency, timeliness and quality of outcomes. Objective This mixed methods study aimed to explore the potential value of an existing telehealth platform to enable collaboration of pharmacists and geriatricians in residential medication reviews. Setting Long term care facilities in Australia. Method Twenty vignettes of aged care residents were prepared and independently reviewed by five pharmacists and five geriatricians using a telehealth platform to record their recommendations for medications. The geriatricians were subsequently asked to re-consider their recommendations after being provided with a pharmacist's report. Main outcome measure The level of agreement between pharmacists and between geriatricians, changes in the mean number of medications after pharmacists' and geriatricians' reviews, number of changes in geriatricians' recommendations after viewing a pharmacist's report, and pharmacists' and geriatricians' feedback. Results Both pharmacists and geriatricians had fair agreement about their recommendations for medications (kappa of 0.30 and 0.31 respectively). The mean number of medications over 20 cases was significantly reduced from a baseline of 14.9 to 13.4 by pharmacists, and to 12.3 by geriatricians after their reviews. There was disagreement between geriatricians and pharmacists on 430/1485 (29%) recommendations on medications; after viewing a pharmacist's report, geriatricians changed their mind in 51 occasions. Geriatricians found the pharmacist report useful in 72% of the cases. The majority of the pharmacists (4/5) were prepared to use the online system routinely. Conclusion The tested telehealth platform has the potential of being used as a part of routine practice to improve accessibility of the service and to enable synchronous collaboration among healthcare professionals.
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Affiliation(s)
- Leila Shafiee Hanjani
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Nancye M Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Christopher R Freeman
- Centre for Optimising Pharmacy Practice-based Excellence in Research, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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35
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Anticholinergic and sedative medications exposure in older patients: a cross-sectional study. Int J Clin Pharm 2019; 41:1152-1158. [DOI: 10.1007/s11096-019-00885-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
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36
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Sloeserwij VM, Hazen ACM, Zwart DLM, Leendertse AJ, Poldervaart JM, de Bont AA, de Gier JJ, Bouvy ML, de Wit NJ. Effects of non-dispensing pharmacists integrated in general practice on medication-related hospitalisations. Br J Clin Pharmacol 2019; 85:2321-2331. [PMID: 31240722 PMCID: PMC6783584 DOI: 10.1111/bcp.14041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 11/18/2022] Open
Abstract
Aims To evaluate the effect of non‐dispensing pharmacists (NDPs) integrated in general practice on medication‐related hospitalisations, drug burden index and costs in patients at high risk of medication problems (being 65 years or older and using 5 or more chronic medications). Methods This was a multicentre, nonrandomised, controlled intervention study with pre–post comparison (2013 vs June 2014 to May 2015) in 25 general practices in the Netherlands, comparing NDP‐led care (intervention) with 2 current pharmaceutical care models (usual care and usual care plus). In the intervention group, 10 specially trained NDPs were employed in general practices to take integral responsibility for the pharmaceutical care. They provided a broad range of medication therapy management services both on patient level (e.g. clinical medication review) and practice level (e.g. quality improvement projects). In the control groups, pharmaceutical care was provided as usual by general practitioners and community pharmacists, or as usual plus, when pharmacists were additionally trained in performing medication reviews. Results Overall, 822 medication‐related hospitalisations were identified among 11 281 high‐risk patients during the intervention period. After adjustment for clustering and potential confounders, the rate ratio of medication‐related hospitalisations in the intervention group compared to usual care was 0.68 (95% confidence interval: 0.57–0.82) and 1.05 (95% confidence interval: 0.73–1.52) compared to usual care plus. No differences in drug burden index or costs were found. Conclusions In general practices with an integrated NDP, the rate of medication‐related hospitalisations is lower compared to usual care. No differences with usual care plus were found.
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Affiliation(s)
- V M Sloeserwij
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - A C M Hazen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - D L M Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - A J Leendertse
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - J M Poldervaart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
| | - A A de Bont
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - J J de Gier
- Department of Pharmacotherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - M L Bouvy
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - N J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Utrecht, The Netherlands
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Soong C, Burry L, Cho HJ, Gathecha E, Kisuule F, Tannenbaum C, Vijenthira A, Morgenthaler T. An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients. JAMA Intern Med 2019; 179:965-972. [PMID: 31157831 DOI: 10.1001/jamainternmed.2019.1196] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sedative-hypnotic medications are frequently prescribed for hospitalized patients with insomnia, but they can result in preventable harm such as delirium, falls, hip fractures, and increased morbidity. Furthermore, sedative-hypnotic initiation while in the hospital carries a risk of chronic use after discharge. Disrupted sleep is a major contributor to sedative-hypnotic use among patients in the hospital and other institutional settings. Numerous multicomponent studies on improving sleep quality in these settings have been described, some demonstrating an associated reduction of sedative-hypnotic prescriptions. This selected review summarizes effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation and proposes an implementation strategy to guide quality improvement teams.
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Affiliation(s)
- Christine Soong
- Division of General Internal Medicine, Sinai Health System, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada.,Centre for Quality and Patient Safety, University of Toronto, Ontario, Canada
| | - Lisa Burry
- Division of General Internal Medicine, Sinai Health System, Toronto, Ontario, Canada.,Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Hyung J Cho
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Lown Institute, Brookline, Massachusetts
| | - Evelyn Gathecha
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Flora Kisuule
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
| | - Abi Vijenthira
- Postgraduate Medical Education, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Morgenthaler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
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Pharmacists' perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study. Int J Clin Pharm 2019; 41:950-962. [PMID: 31123899 DOI: 10.1007/s11096-019-00821-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/28/2019] [Indexed: 10/26/2022]
Abstract
Background Medication reviews by pharmacists have been shown to identify and reduce drug-related problems in long-term care residents. Objective To explore pharmacist perspectives of the Australian Government funded pharmacist-conducted residential medication management review and its role improving the quality and safety of prescribing in long-term care, in particular for those living with advanced dementia. Setting Australian Long-term care pharmacists. Method A qualitative research methodology approach using semi-structured interviews was used, with participants pharmacists with Residential Medication Management Review experience. Interviews were recorded, transcribed and coded utilising a meta-model of Physician-Community Pharmacy Collaboration in medication review. Main outcome measure Pharmacists' perspectives on the Residential Medication Management Review and how to improve the quality of reviews for residents with advanced dementia. Results Fifteen accredited pharmacists participated. The majority believed that the Residential Medication Management Review had the potential to improve the quality and safety of medicines but highlighted systemic issues that worked against collaborative practice. Participants emphasised the importance of three-way collaboration between general practitioners, pharmacists and nursing staff and highlighted key strategies for its optimisation. Conclusion Incorporating avenues for greater communication between team members can improve collaboration between health professionals and ultimately the quality of medication reviews.
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Byrne CJ, Walsh C, Cahir C, Bennett K. Impact of drug burden index on adverse health outcomes in Irish community-dwelling older people: a cohort study. BMC Geriatr 2019; 19:121. [PMID: 31035946 PMCID: PMC6489229 DOI: 10.1186/s12877-019-1138-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 04/16/2019] [Indexed: 11/24/2022] Open
Abstract
Background The Drug Burden Index (DBI) quantifies exposure to medications with anticholinergic and/or sedative effects. A consensus list of DBI medications available in Ireland was recently developed for use as a DBI tool. The aim of this study was to validate this DBI tool by examining the association of DBI score with important health outcomes in Irish community-dwelling older people. Methods This was a cohort study using data from The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data. Individuals aged ≥65 years participating in TILDA and enrolled in the General Medical Services scheme were eligible for inclusion. DBI score was determined by applying the DBI tool to participants’ medication dispensing data in the year prior to outcome assessment. DBI score was recoded into a categorical variable [none (0), low (> 0 and < 1), and high (≥1)]. Outcome measures included any Activities of Daily Living (ADL) impairment, any Instrumental Activities of Daily Living (IADL) impairment, any self-reported fall in the previous 12 months, any frailty criterion met (Fried Phenotype measure), quality of life (QoL) score (CASP-19 [Control Autonomy Self-realisation Pleasure] measure), and healthcare utilisation (any hospital admission and any emergency department (ED) visit) in the previous 12 months. Statistical analyses included multivariate logistic and linear regression models controlling for potential confounders. Results 61.3% (n = 1946) of participants received at least one DBI prescription in the year before their outcome assessment. High DBI exposure (DBI score ≥ 1) vs none was significantly associated with impaired function (ADL impairment adjusted OR 1.89, 95% CI 1.25, 2.88; IADL impairment adjusted OR 2.97, 95% CI 1.91, 4.61), self-reported falls (adjusted OR 1.50, 95%CI 1.03, 2.18), frailty (adjusted OR 1.74, 95% CI 1.14, 2.67), and reduced QoL (β = − 1.84, 95%CI -3.14, − 0.54). There was no significant association between DBI exposure and healthcare utilisation. Conclusions The findings validate the use of the DBI tool for predicting risk of functional impairment, falls, frailty and reduced QoL in older people in Ireland, and may be extended to other European countries. Integration of this tool into routine practice may be an appropriate step forward to improve outcomes in older people.
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Affiliation(s)
- Catherine J Byrne
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Caroline Walsh
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitriona Cahir
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Kouladjian O'Donnell L, Gnjidic D, Chen TF, Hilmer SN. Integration of an electronic Drug Burden Index risk assessment tool into Home Medicines Reviews: deprescribing anticholinergic and sedative medications. Ther Adv Drug Saf 2019; 10:2042098619832471. [PMID: 30858967 PMCID: PMC6402056 DOI: 10.1177/2042098619832471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 01/30/2019] [Indexed: 01/31/2023] Open
Abstract
Background: Our aim in this research was to establish whether integrating an electronically generated calculation and report on the Drug Burden Index (DBI) in the Home Medicines Review (HMR) setting is an accurate, feasible and useful risk assessment tool to assess risk of anticholinergic and sedative medications; and to establish whether the intervention of DBI together with HMR is associated with a reduced use of anticholinergic and sedative medications in older community-dwelling adults in Australia. Methods: An interventional feasibility study was conducted. Accredited clinical pharmacists (APs) were recruited to participate. Each AP was educated on implementation of the DBI into HMR practice and given access to the DBI Calculator© web-based software to generate the DBI report for inclusion in HMR reports for general practitioners (GPs). APs recruited patients (⩾65 years) who were referred to them for HMRs. Patients were sent a letter about their DBI exposure, and a prompt to visit their GP to discuss their medication management options. GPs, APs and patients were asked to evaluate the feasibility and utility of the DBI report. A medication inventory was collected from patients at the time of the HMR and at 3 months to determine whether the intervention affected deprescribing of medications with anticholinergic and sedative effects. Results: Regarding the feasibility of the DBI report as a risk assessment tool within HMR, 89% of APs and 67% of GPs agreed that it would be feasible. The DBI Calculator© was potentially inaccurate, as 26% of DBI scores were underestimated and 7% were overestimated (at baseline). At 3 months, the median (interquartile range) DBI for patients (n = 100) significantly decreased from 0.82 (0–1.33) to 0.67 (0–1.29) (p = 0.014). Additionally, of patients with a DBI > 0 (n = 66), 36.4% had their DBI score decrease, and 6.1% had a score increase. Conclusion: This study demonstrated that integration of the DBI Calculator© into HMR is a feasible and useful method to prompt deprescribing of anticholinergic and sedative medications in older adults. There is potential for the accuracy of the web-based platform to be improved. Registration of trial: Name: Feasibility study of the Drug Burden Index with Home Medicines Review. Website: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368523 Trial ID: ACTRN 12615000539538.
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Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Level 13 Kolling Building, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School University of Sydney, NSW, Australia
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McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial. J Clin Pharm Ther 2019; 44:595-602. [DOI: 10.1111/jcpt.12822] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/09/2019] [Accepted: 01/18/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Nicole McDerby
- Discipline of Pharmacy; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
| | - Sam Kosari
- Discipline of Pharmacy; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
| | - Kasia Bail
- Discipline of Nursing; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
| | - Alison Shield
- Discipline of Pharmacy; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
| | - Gregory Peterson
- Discipline of Pharmacy; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
- School of Pharmacy; University of Tasmania; Hobart Tasmania Australia
| | - Mark Naunton
- Discipline of Pharmacy; Faculty of Health; University of Canberra; Bruce Australian Capital Territory Australia
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42
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Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. Int J Clin Pharm 2019; 41:167-178. [PMID: 30659492 DOI: 10.1007/s11096-019-00784-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/09/2019] [Indexed: 12/17/2022]
Abstract
Background Prolonged use of anticholinergic and sedative medicines is correlated with worsening cognition and physical function decline. Deprescribing is a proposed intervention that can help to minimise polypharmacy whilst potentially improving several health outcomes in older people. Objective This study aimed to examine the feasibility of implementing a deprescribing intervention that utilises a patient-centred pharmacist-led intervention model; in order to address major deprescribing challenges such as general practitioner time constraints and lack of accessible deprescribing guidelines and processes. Setting Three residential care facilities. Methods The intervention involved a New Zealand registered pharmacist utilising peer-reviewed deprescribing guidelines to recommend targeted deprescribing of anticholinergic and sedative medicines to GPs. Main outcome measure The change in the participants' Drug Burden Index (DBI) total and DBI 'as required' (PRN) was assessed 3 and 6 months after implementing the deprescribing intervention. Results Seventy percent of potential participants were recruited for the study (n = 46), and 72% of deprescribing recommendations suggested by the pharmacist were implemented by General Pratitioners (p = 0.01; Fisher's exact test). Ninety-six percent of the residents agreed to the deprescribing recommendations, emphasising the importance of patient centred approach. Deprescribing resulted in a significant reduction in participants' DBI scores by 0.34, number of falls and adverse drug reactions, 6 months post deprescribing. Moreover, participants reported lower depression scores and scored lower frailty scores 6 months after deprescribing. However, cognition did not improve; nor did participants' reported quality of life. Conclusion This patient-centred deprescribing approach, demonstrated a high uptake of deprescribing recommendations and success rate. After 6 months, significant benefits were noted across a range of important health measures including mood, frailty, falls and reduced adverse reactions. This further supports deprescribing as a possible imperative to improve health outcomes in older adults.
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Affiliation(s)
| | - Dee Mangin
- University of Otago, Christchurch, New Zealand
- David Braley Nancy Gordon, Chair in Family Medicine, McMaster University, Hamilton, ON, Canada
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43
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Sawan M, Chen TF, Jeon YH, Hilmer SN. Organisational culture must be addressed to reduce psychotropic prescribing in Residential Aged Care Facilities. Aust N Z J Psychiatry 2019; 53:87. [PMID: 29911394 DOI: 10.1177/0004867418781490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mouna Sawan
- 1 The University of Sydney School of Medicine, NHMRC Cognitive Decline Partnership Centre, Faculty of Medicine and Health, Camperdown, NSW, Australia
| | - Timothy F Chen
- 2 The University of Sydney School of Pharmacy, Faculty of Medicine and Health, Camperdown, NSW, Australia
| | - Yun-Hee Jeon
- 3 The University of Sydney School of Nursing, Faculty of Medicine and Health, Camperdown, NSW, Australia
| | - Sarah N Hilmer
- 1 The University of Sydney School of Medicine, NHMRC Cognitive Decline Partnership Centre, Faculty of Medicine and Health, Camperdown, NSW, Australia
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Aspinall SL, Hanlon JT, Niznik JD, Springer SP, Thorpe CT. Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification. Innov Aging 2018; 1:igx031. [PMID: 30564752 DOI: 10.1093/geroni/igx031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 01/15/2023] Open
Abstract
Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.
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Affiliation(s)
- Sherrie L Aspinall
- VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, Illinois.,VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Joshua D Niznik
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania.,Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pennsylvania
| | - Sydney P Springer
- VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, Illinois.,VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
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Approaches to Deprescribing Psychotropic Medications for Changed Behaviours in Long-Term Care Residents Living with Dementia. Drugs Aging 2018; 36:125-136. [DOI: 10.1007/s40266-018-0623-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Pouranayatihosseinabad M, Zaidi TS, Peterson G, Nishtala PS, Hannan P, Castelino R. The impact of residential medication management reviews (RMMRs) on medication regimen complexity. Postgrad Med 2018; 130:575-579. [PMID: 30091394 DOI: 10.1080/00325481.2018.1502016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The primary objective of this study was to investigate the impact of RMMRs on medication regimen complexity, as assessed by a validated measure. METHODS Retrospective analysis of RMMRs pertaining to 285 aged care residents aged ≥ 65 years in Sydney, Australia. Medication regimen complexity was measured using the Medication Regimen Complexity Index (MRCI) at baseline, after pharmacists' recommendations (assuming that all of the pharmacists' recommendations were accepted by the General Practitioner (GP)), and after the actual uptake of pharmacists' recommendations by the GP. Differences in the regimen complexity was measured using the Wilcoxon sign rank test. RESULTS Pharmacists made 764 recommendations (average 2.7 recommendations per RMMR), of which 569 (74.5%) were accepted by GPs. The median MRCI at baseline in the sample was 25.5 (IQR = 19.0-32.5). No statistically significant differences were demonstrated in the MRCI scores after pharmacists' recommendations (p = 0.53) or after GPs' acceptance of these recommendations (p = 0.07) compared to the baseline. CONCLUSION Our study revealed high acceptance of pharmacists' recommendations by GPs. This suggests that RMMRs are useful for identifying and resolving drug-related issues among residents of ACFs. However, our study failed to show a significant effect of RMMRs in reducing the medication regimen complexity, as measured by the MRCI. Further studies are needed to establish the association of medication regimen complexity and clinical outcomes in residents of ACFs.
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Affiliation(s)
| | | | - Gregory Peterson
- a University of Tasmania School of Pharmacy , Hobart , Australia
| | - Prasad S Nishtala
- b University of Otago New Zealand's National School of Pharmacy , Dunedin , New Zealand
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Jamieson HA, Nishtala PS, Scrase R, Deely JM, Abey-Nesbit R, Hilmer SN, Abernethy DR, Berry SD, Mor V, Lacey CJ, Schluter PJ. Drug Burden Index and Its Association With Hip Fracture Among Older Adults: A National Population-Based Study. J Gerontol A Biol Sci Med Sci 2018; 74:1127-1133. [DOI: 10.1093/gerona/gly176] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
- Older Persons Health Specialist Service, Burwood Hospital, Christchurch, New Zealand
| | | | - Richard Scrase
- Department of Nursing, Canterbury District Health Board, Christchurch, New Zealand
| | - Joanne M Deely
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Sarah N Hilmer
- Cognitive Decline Partnership Centre, Ageing and Pharmacology, Kolling Institute of Medical Research, School of Medicine, University of Sydney, St Leonards, NSW, Australia
| | - Darrell R Abernethy
- Drug Safety Office of Clinical Pharmacology, U.S. FDA, U.S. Department of Health and Human Services, Baltimore, Maryland
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, School of Public Health, Providence, Rhode Island
| | - Cameron J Lacey
- Department of Medicine, University of Otago, Christchurch, New Zealand
- West Coast District Health Board, Greymouth
| | - Philip J Schluter
- School of Health Sciences, College of Education, Health and Human Development University of Canterbury, Christchurch, New Zealand
- Primary Care Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia
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Byrne CJ, Walsh C, Cahir C, Ryan C, Williams DJ, Bennett K. Anticholinergic and sedative drug burden in community-dwelling older people: a national database study. BMJ Open 2018; 8:e022500. [PMID: 29982221 PMCID: PMC6045724 DOI: 10.1136/bmjopen-2018-022500] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The Drug Burden Index (DBI) tool quantifies individual exposure to anticholinergic and sedative medications. The DBI has been internationally validated against adverse health outcomes in older people. DBI exposure has not been reported in the Irish older population. This study aimed to: (1) develop a list of drugs with clinically significant anticholinergic and/or sedative effects (DBI medications) relevant to Ireland; (2) examine, using the DBI formula, the prevalence of exposure to DBI medications in Irish older people and (3) explore patient factors associated DBI exposure. DESIGN A cross-sectional national pharmacy claims database study. SETTING Community setting using the General Medical Services (GMS) scheme pharmacy claims database maintained by the Health Service Executive Primary Care Reimbursement Services. PARTICIPANTS Irish older individuals (aged ≥65 years) enrolled in the GMS scheme and dispensed at least one prescription item in 2016 (n=428 516). MAIN OUTCOME MEASURES Prevalence of exposure to DBI medications and patient factors associated with DBI exposure. RESULTS 282 874 (66%) of the GMS population aged ≥65 years were exposed to at least one DBI medication in 2016. Prevalence of exposure to DBI medications was significantly higher in females than males (females 71.6% vs males 58.7%, adjusted OR 1.65, 95% CI 1.63 to 1.68). Prevalence of DBI exposure increased progressively with the number of chronic drugs used, rising from 42.7% of those prescribed 0-4 chronic drugs to 95.4% of those on ≥12 chronic drugs (adjusted OR 27.8, 95% CI 26.7 to 29.0). The most frequently used DBI medications were codeine/paracetamol combination products (20.1% of patients), tramadol (11.5%), zopiclone (9.5%), zolpidem (8.5%), pregabalin (7.9%) and alprazolam (7.8%). CONCLUSIONS The majority of older people in Ireland are exposed to medications with anticholinergic and/or sedative effects, particularly females and those with multiple comorbidities. The high use of low-dose codeine/paracetamol combination products, Z-drugs and benzodiazepines, suggests there are opportunities for deprescribing.
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Affiliation(s)
- Catherine J Byrne
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caroline Walsh
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitriona Cahir
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cristín Ryan
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Kalisch Ellett LM, Pratt NL, Sluggett JK, Ramsay EN, Kerr M, LeBlanc VT, Barratt JD, Gilbert AL, Roughead EE. Sustaining practice change in health care: the impact of a national quality improvement program on the uptake of collaborative medicines reviews. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Janet K. Sluggett
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Emmae N. Ramsay
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Mhairi Kerr
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Vanessa T. LeBlanc
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - John D. Barratt
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Andrew L. Gilbert
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre Sansom Institute for Health Research University of South Australia Adelaide Australia
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Koria LG, Zaidi TS, Peterson G, Nishtala P, Hannah PJ, Castelino R. Impact of medication reviews on inappropriate prescribing in aged care. Curr Med Res Opin 2018; 34:833-838. [PMID: 29301404 DOI: 10.1080/03007995.2018.1424624] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Inappropriate prescribing (IP) is prevalent among elderly people in aged care facilities. Little has been published on the effect of pharmacists performing residential medication management reviews (RMMRs) in aged care on the appropriateness of prescribing. RMMRs represents a key strategy for achieving quality use of medicines, by assisting residents in aged care facilities and their carers to better manage their medicines. However, the structure of RMMR has moved from annual to every two years for each resident. OBJECTIVES The primary objective of this study was to investigate the impact of pharmacists performing RMMRs on medication use appropriateness, as measured by the Medication Appropriateness Index (MAI). METHODS Retrospective analysis of RMMRs pertaining to 223 aged care residents aged ≥65 years in Sydney, Australia. The MAI was applied on two RMMR cohorts; newer cohort (n = 111, 2015) i.e. following the recent changes to the RMMR funding and older cohort (n = 112, 2012) at baseline, after pharmacists' recommendations (assuming all pharmacists' recommendations were accepted by the General Practitioner [GP]), and after the actual uptake of pharmacists' recommendations by the GP. Differences in inappropriate prescribing were measured using the Wilcoxon sign rank test. RESULTS Overall, all patients in the study (n = 223) had at least one inappropriate rating at baseline (median MAI score of 26 for the old cohort and 27 for the newer cohort). The median cumulative MAI scores were significantly lower after the RMMRs by pharmacists (15.5 and 20 for the old and new cohort respectively, p < .001) and following the uptake of recommendations by the GP, indicating an increased appropriateness of drug regimen after the medication review (20 and 22 for the old and new cohort respectively, p < .001). CONCLUSION This study shows that pharmacist-led medication reviews are effective in reducing inappropriate prescribing among aged care residents, as demonstrated by the reduction in MAI scores. Future studies should focus on the impact of such a decrease on patient outcomes.
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Affiliation(s)
- Linda Ghali Koria
- a Department of Pharmacy , University of Tasmania , Hobart , Tasmania , Australia
| | - Tabish Syed Zaidi
- a Department of Pharmacy , University of Tasmania , Hobart , Tasmania , Australia
| | - Gregory Peterson
- a Department of Pharmacy , University of Tasmania , Hobart , Tasmania , Australia
| | - Prasad Nishtala
- b Department of Pharmacy , University of Otago , Dunedin , New Zealand
| | - Paul J Hannah
- c Meditrax , Annandale , New South Wales , Australia
| | - Ronald Castelino
- a Department of Pharmacy , University of Tasmania , Hobart , Tasmania , Australia
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