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Liau SJ, Zhao M, Hamada S, Gutiérrez-Valencia M, Jadczak AD, Li L, Martínez-Velilla N, Sakata N, Fu P, Visvanathan R, Lalic S, Roncal-Belzunce V, Bell JS. Deprescribing Opportunities for Frail Residents of Nursing Homes: A Multicenter Study in Australia, China, Japan, and Spain. J Am Med Dir Assoc 2024; 25:876-883. [PMID: 38423513 DOI: 10.1016/j.jamda.2024.01.015] [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: 11/17/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Deprescribing opportunities may differ across health care systems, nursing home settings, and prescribing cultures. The objective of this study was to compare the prevalence of STOPPFrail medications according to frailty status among residents of nursing homes in Australia, China, Japan, and Spain. DESIGN Secondary cross-sectional analyses of data from 4 cohort studies. SETTING AND PARTICIPANTS A total of 1142 residents in 31 nursing homes. METHODS Medication data were extracted from resident records. Frailty was assessed using the FRAIL-NH scale (non-frail 0-2; frail 3-6; most-frail 7-14). Chi-square tests and prevalence ratios (PRs) were used to compare STOPPFrail medication use across cohorts. RESULTS In total, 84.7% of non-frail, 95.6% of frail, and 90.6% of most-frail residents received ≥1 STOPPFrail medication. Overall, the most prevalent STOPPFrail medications were antihypertensives (53.0% in China to 73.3% in Australia, P < .001), vitamin D (nil in China to 52.7% in Australia, P < .001), lipid-lowering therapies (11.1% in Japan to 38.9% in Australia, P < .001), aspirin (13.5% in Japan to 26.2% in China, P < .001), proton pump inhibitors (2.1% in Japan to 32.0% in Australia, P < .001), and antidiabetic medications (12.3% in Japan to 23.5% in China, P = .010). Overall use of antihypertensives (PR, 1.15; 95% CI, 1.06-1.25), lipid-lowering therapies (PR, 1.78; 95% CI, 1.45-2.18), aspirin (PR, 1.31; 95% CI, 1.04-1.64), and antidiabetic medications (PR, 1.31; 95% CI, 1.00-1.72) were more prevalent among non-frail and frail residents compared with most-frail residents. Antihypertensive use was more prevalent with increasing frailty in China and Japan, but less prevalent with increasing frailty in Australia. Antidiabetic medication use was less prevalent with increasing frailty in China and Spain but was consistent across frailty groups in Australia and Japan. CONCLUSIONS AND IMPLICATIONS There were overall and frailty-specific variations in prevalence of different STOPPFrail medications across cohorts. This may reflect differences in prescribing cultures, application of clinical practice guidelines in the nursing home setting, and clinician or resident attitudes toward deprescribing.
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Affiliation(s)
- Shin J Liau
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.
| | - Meng Zhao
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Shota Hamada
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan; Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Marta Gutiérrez-Valencia
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain; Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain
| | - Agathe D Jadczak
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Aged and Extended Care Services and the Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Li Li
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Nicolás Martínez-Velilla
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Navarrabiomed, Public University of Navarra (UPNA), Pamplona, Navarre, Spain; Department of Geriatrics, Hospital Universitario de Navarra (HUN), Pamplona, Navarre, Spain
| | - Nobuo Sakata
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Peipei Fu
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Aged and Extended Care Services and the Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia; Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Victoria Roncal-Belzunce
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Navarrabiomed, Public University of Navarra (UPNA), Pamplona, Navarre, Spain
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
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Niznik JD, Shmuel S, Pate V, Thorpe CT, Hanson LC, Rice C, Lund JL. Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data. Pharmacoepidemiol Drug Saf 2024; 33:e5784. [PMID: 38556843 PMCID: PMC11145562 DOI: 10.1002/pds.5784] [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: 08/08/2023] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Limited research has evaluated the validity of claims-based definitions for deprescribing. OBJECTIVES Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. METHODS We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. RESULTS Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. CONCLUSIONS The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shahar Shmuel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Schleiden LJ, Klima G, Rodriguez KL, Ersek M, Robinson JE, Hickson RP, Smith D, Cashy J, Sileanu FE, Thorpe CT. Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life. Drugs Aging 2024; 41:367-377. [PMID: 38575748 PMCID: PMC11021174 DOI: 10.1007/s40266-024-01110-3] [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] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Gloria Klima
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jacob E Robinson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - John Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Christiaens A, Simon-Tillaux N, Thompson W, Sinclair AJ, Henrard S, Boland BB, Slaouti-Jégou Y, Lekens B, Bonnet-Zamponi D, Tubach F, Zerah L. Impact of deintensifying hypoglycaemic drugs in older adults with type 2 diabetes: protocol for an emulation of a target trial. BMJ Open 2023; 13:e073081. [PMID: 37984943 PMCID: PMC10660441 DOI: 10.1136/bmjopen-2023-073081] [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: 02/22/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION In older adults with type 2 diabetes (T2D), overtreatment with hypoglycaemic drugs (HDs: sulfonylureas, glinides and/or insulins) is frequent and associated with increased 1-year mortality. Deintensification of HD is thus a key issue, for which evidence is though limited. The primary objective of this study will be to estimate the effect of deintensifying HD on clinical outcomes (hospital admission or death) within 3 months in older adults (≥75 years) with T2D. METHODS We will emulate with real-world data a target trial, within The Health Improvement Network cohort, a large-scale database of data collected from electronic medical records of 2000 general practitioners in France. From 1 January 2010 to 28 February 2019, we will include eligible patients ≥75 years who will have T2D, a stable dose of HDs, glycated haemoglobin A1c (HbA1c) value <75 mmol/mol (9.0%) and no deintensification in the past year. The target trial will be sequentially emulated (ie, eligibility assessed) every month in the database. Patients will be classified at baseline of each sequential trial in the intervention arm (deintensification of HDs: decrease of ≥50% in the total dose of HDs, including complete cessation) or control arm (no deintensification of HDs). The pooled dataset for all sequential emulated trials will be analysed. The primary outcome will be time to first occurrence of hospital admission or death, within 3 months. Secondary outcomes will be hospitalisation, death, appropriateness of glycaemic control and occurrence of HbA1c >75 mmol/mol within 1 year. Participants will be followed from baseline to 12 months after randomisation, administrative censoring, or death, whichever occurs first. A pooled logistic regression will be used to estimate the treatment effect on the incidence of the outcomes. DISSEMINATION AND ETHICS No ethical approval is needed for using retrospectively this fully anonymised database. The results will be disseminated during conferences and through publications in scientific journals.
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Affiliation(s)
- Antoine Christiaens
- FNRS, Fund for Scientific Research, Bruxelles, Belgium
- Clinical Pharmacy research group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, Île-de-France, France
| | - Noémie Simon-Tillaux
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, Île-de-France, France
- Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité́ de Recherche Clinique PSL-CFX, CIC-1901, Assistance Publique - Hôpitaux de Paris, Paris, Île-de-France, France
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Alan J Sinclair
- Care for long term conditions - Diabetes research group, King's College London, London, UK
- Foundation for Diabetes Research in Older People, Taplow, UK
| | - Séverine Henrard
- Clinical Pharmacy research group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Benoit B Boland
- Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
- Geriatric Department, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | | | | | - Dominique Bonnet-Zamponi
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, Île-de-France, France
- Observatoire des médicaments, dispositifs médicaux, innovations thérapeutiques d'Île-de-France, Paris, France
| | - Florence Tubach
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, Île-de-France, France
- Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité́ de Recherche Clinique PSL-CFX, CIC-1901, Assistance Publique - Hôpitaux de Paris, Paris, Île-de-France, France
| | - Lorène Zerah
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, Île-de-France, France
- Hôpital Pitié Salpêtrière, Département de gériatrie, Assistance Publique - Hôpitaux de Paris, Paris, Île-de-France, France
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Rantz M, Ersek M. Care Delivery, Quality Measurement, and Quality Improvement in Nursing Homes: Issues and Recommendations from the National Academies' Report on the Quality of Care in Nursing Homes. J Am Geriatr Soc 2023; 71:329-334. [PMID: 36795629 DOI: 10.1111/jgs.18275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Affiliation(s)
- Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute and School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Diabetes im Alter: Deintensivierung einer strengen glykämischen Kontrolle. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1733-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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