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Groos SS, de Wildt KK, van de Loo B, Linn AJ, Medlock S, Shaw KM, Herman EK, Seppala LJ, Ploegmakers KJ, van Schoor NM, van Weert JCM, van der Velde N. Development of the ADFICE_IT clinical decision support system to assist deprescribing of fall-risk increasing drugs: A user-centered design approach. PLoS One 2024; 19:e0297703. [PMID: 39236057 PMCID: PMC11376580 DOI: 10.1371/journal.pone.0297703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 08/20/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Deprescribing fall-risk increasing drugs (FRIDs) is promising for reducing the risk of falling in older adults. Applying appropriate deprescribing in practice can be difficult due to the outcome uncertainties associated with stopping FRIDs. The ADFICE_IT intervention addresses this complexity with a clinical decision support system (CDSS) that facilitates optimum deprescribing of FRIDs by using a fall-risk prediction model, aggregation of deprescribing guidelines, and joint medication management. METHODS The development process of the CDSS is described in this paper. Development followed a user-centered design approach in which users and experts were involved throughout each phase. In phase I, a prototype of the CDSS was developed which involved a literature and systematic review, European survey (n = 581), and semi-structured interviews with clinicians (n = 19), as well as the aggregation and testing of deprescribing guidelines and the development of the fall-risk prediction model. In phase II, the feasibility of the CDSS was tested by means of two usability testing rounds with users (n = 11). RESULTS The final CDSS consists of five web pages. A connection between the Electronic Health Record allows for the retrieval of patient data into the CDSS. Key design requirements for the CDSS include easy-to-use features for fast-paced clinical environments, actionable deprescribing recommendations, information transparency, and visualization of the patient's fall-risk estimation. Key elements for the software include a modular architecture, open source, and good security. CONCLUSION The ADFICE_IT CDSS supports physicians in deprescribing FRIDs optimally to prevent falls in older patients. Due to continuous user and expert involvement, each new feedback round led to an improved version of the system. Currently, a cluster-randomized controlled trial with process evaluation at hospitals in the Netherlands is being conducted to test the effect of the CDSS on falls. The trial is registered with ClinicalTrials.gov (date; 7-7-2022, identifier: NCT05449470).
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Affiliation(s)
- Sara S Groos
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Kelly K de Wildt
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Bob van de Loo
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Annemiek J Linn
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, the Netherlands
| | - Stephanie Medlock
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
- Department of Medical Informatics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Stichting Open Electronics Lab, Maarssen, The Netherlands
| | - Kendrick M Shaw
- Stichting Open Electronics Lab, Maarssen, The Netherlands
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | | | - Lotta J Seppala
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Kim J Ploegmakers
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Natasja M van Schoor
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Julia C M van Weert
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, the Netherlands
| | - Nathalie van der Velde
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Shantsila E, Lip GYH, Shantsila A, Kurpas D, Beevers G, Gill PS, Williams NH. Antihypertensive treatment in people of very old age with frailty: time for a paradigm shift? J Hypertens 2023; 41:1502-1510. [PMID: 37432893 DOI: 10.1097/hjh.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Donata Kurpas
- Health Sciences Faculty, Wrocław Medical University, Wrocław, Poland
- Primary Care and Risk Factor Management Section, European Association of Preventative Cardiology, European Heart House, Les Templiers, Sophia Antipolis
- International Advisory Board of EURIPA (WONCA) - France
- International Foundation for Integrated Care (IFIC), Schiphol Airport, The Netherlands
| | - Gareth Beevers
- University of Birmingham, Department of Medicine, City Hospital, Birmingham
| | - Paramjit S Gill
- Academic Unit of Primary Care Warwick Medical School, University of Warwick Coventry, UK
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool
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van Poelgeest E, van der Velde N. A themed journal issue on (de)prescribing dilemmas in older, multimorbid adults with increased fall risk. Eur Geriatr Med 2023; 14:645-648. [PMID: 37542645 DOI: 10.1007/s41999-023-00845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Affiliation(s)
- Eveline van Poelgeest
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Liu E, Nahid M, Musse M, Chen L, Hilmer SN, Zullo A, Kwak MJ, Lachs M, Levitan EB, Safford MM, Goyal P. Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure. BMC Cardiovasc Disord 2023; 23:372. [PMID: 37495948 PMCID: PMC10373421 DOI: 10.1186/s12872-023-03401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden. METHODS We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors. RESULTS Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14). CONCLUSIONS FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.
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Affiliation(s)
- Esther Liu
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah N Hilmer
- The University of Sydney and Royal North Shore Hospital, Sydney, NSW, Australia
| | - Andrew Zullo
- Brown University School of Public Health, Providence, USA
| | | | - Mark Lachs
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | | | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, 525 East 68Th Street, New York, NY, 10021, USA.
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Gillespie R, Mullan J, Harrison L. Exploring Older Adult Health Literacy in the Day-to-Day Management of Polypharmacy and Making Decisions About Deprescribing: A Mixed Methods Study. Health Lit Res Pract 2023; 7:e14-e25. [PMID: 36629783 PMCID: PMC9833258 DOI: 10.3928/24748307-20221216-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/22/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Polypharmacy use in older adults is increasing and sometimes leads to poor health outcomes. The influence of health literacy in managing polypharmacy and making decisions about stopping medication has received limited attention. OBJECTIVE A mixed methods design was used to measure and investigate the influence of health literacy in the management of polypharmacy and decisions about deprescribing. Phase 1 involved two cross-sectional surveys, one with older adults using five or more medications and the other with general practitioners (GPs). METHODS Older adult health literacy was measured using the All Aspects of Health Literacy Scale. Phase 2 employed individual interviews with both older adults and GPs and further explored the reported use of health literacy in practice. SPSS version 24 was used to conduct descriptive statistical analysis of the Phase 1 survey responses and Phase 2 interviews were analyzed using thematic analysis with the assistance of NVivo 12. KEY RESULTS Phase 1 survey responses were received from 85 GPs and 137 older adults. Phase 2 interviews were conducted with 16 GPs and 25 older adults. Phase 1 results indicated that self-reported older adult health literacy was high, and that GPs believed older patients could engage in decisions about deprescribing. Phase 2 findings showed that older adults developed and employed complex health literacy practices to manage medications between consultations; however, few reported using their health literacy skills in consultations with their GPs. GPs noted that older adult involvement in decision-making varied and generally thought that older adults had low health literacy. CONCLUSION Older adults reported using health literacy practices in the management of their sometimes-complex medication regimens. However, the role of health literacy in deprescribing decision-making was limited. The mixed methods approach allowed greater insight into older adult and GP practices that influence the acquisition and use of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(1):e14-e25.] Plain Language Summary: This report explores health literacy in the use of multiple medications and decisions to stop using medication/s in older age. Older adults reported good heath literacy and practiced many health literacy skills in the management of their medications. However, they did not always report the use of their health literacy skills when discussing their medications with their family doctor.
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Affiliation(s)
- Robyn Gillespie
- Address correspondence to Robyn Gillespie, PhD, MPH, BN, via
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Ploegmakers KJ, Medlock S, Linn AJ, Lin Y, Seppälä LJ, Petrovic M, Topinkova E, Ryg J, Mora MAC, Landi F, Thaler H, Szczerbińska K, Hartikainen S, Bahat G, Ilhan B, Morrissey Y, Masud T, van der Velde N, van Weert JCM. Barriers and facilitators in using a Clinical Decision Support System for fall risk management for older people: a European survey. Eur Geriatr Med 2022; 13:395-405. [PMID: 35032323 DOI: 10.1007/s41999-021-00599-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Fall-Risk Increasing Drugs (FRIDs) are an important and modifiable fall-risk factor. A Clinical Decision Support System (CDSS) could support doctors in optimal FRIDs deprescribing. Understanding barriers and facilitators is important for a successful implementation of any CDSS. We conducted a European survey to assess barriers and facilitators to CDSS use and explored differences in their perceptions. METHODS We examined and compared the relative importance and the occurrence of regional differences of a literature-based list of barriers and facilitators for CDSS usage among physicians treating older fallers from 11 European countries. RESULTS We surveyed 581 physicians (mean age 44.9 years, 64.5% female, 71.3% geriatricians). The main barriers were technical issues (66%) and indicating a reason before overriding an alert (58%). The main facilitators were a CDSS that is beneficial for patient care (68%) and easy-to-use (64%). We identified regional differences, e.g., expense and legal issues were barriers for significantly more Eastern-European physicians compared to other regions, while training was selected less often as a facilitator by West-European physicians. Some physicians believed that due to the medical complexity of their patients, their own clinical judgement is better than advice from the CDSS. CONCLUSION When designing a CDSS for Geriatric Medicine, the patient's medical complexity must be addressed whilst maintaining the doctor's decision-making autonomy. For a successful CDSS implementation in Europe, regional differences in barrier perception should be overcome. Equipping a CDSS with prediction models has the potential to provide individualized recommendations for deprescribing FRIDs in older falls patients.
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Affiliation(s)
- Kim J Ploegmakers
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, D3-227, Meibergdreef 9, Amsterdam, 1105AZ, The Netherlands.
| | - Stephanie Medlock
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Annemiek J Linn
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, The Netherlands
| | - Yumin Lin
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, The Netherlands.,Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore, Singapore
| | - Lotta J Seppälä
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, D3-227, Meibergdreef 9, Amsterdam, 1105AZ, The Netherlands
| | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Eva Topinkova
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic.,Faculty of Health and Social Sciences, South Bohemian University, Ceske Budejovice, Czech Republic
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Francesco Landi
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Heinrich Thaler
- Trauma Center Wien-Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Gulistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Şişli Hamidiye Etfal Training and Research Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Yvonne Morrissey
- Health Care of Older People, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, D3-227, Meibergdreef 9, Amsterdam, 1105AZ, The Netherlands
| | - Julia C M van Weert
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, The Netherlands
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Kalim RA, Cunningham CJ, Ryder SA, McMahon NM. Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF). Drugs Aging 2022; 39:935-947. [PMID: 36409404 PMCID: PMC9676799 DOI: 10.1007/s40266-022-00985-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting. METHOD Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software. RESULTS A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome. CONCLUSION Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.
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Affiliation(s)
- Reham A Kalim
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Conal J Cunningham
- St James's Hospital, James's Street, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Sheila A Ryder
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Niamh M McMahon
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- St James's Hospital, James's Street, Dublin, Ireland
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Soares CR, Fukujima MM, Costa PCPD, Neves VR, Rosa ADS, Okuno MFP. ADHERENCE AND BARRIERS TO DRUG THERAPY: RELATIONSHIP WITH THE RISK OF FALLS IN OLDER ADULTS. TEXTO & CONTEXTO ENFERMAGEM 2022. [DOI: 10.1590/1980-265x-tce-2020-0552] [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] Open
Abstract
ABSTRACT Objective: to verify the association of adherence and barriers to drug therapy with the risk of falls and the sociodemographic, clinical and economic variables. Method: a cross-sectional study, carried out with 117 aged individuals in a Medical Clinic of Specialties for Older Adults in the Southeast region of the city of São Paulo (SP), from March to November 2019. The following scales were applied: Downton Fall Risk, Morisky-Green Test and Brief Medication Questionnaire. Logistic regression was use to verify the association between adherence to the treatment and types of barriers to adherence and the risk of falls. A 5% significance level was used. Results: the older adults with low adherence to the drug treatment presented 5.57 times more chances of having a high risk of falling when compared to those with greater adherence, and those with a barrier in the recall domain had 22.75 times more chances of having a high risk of falling, in relation to the aged individuals without barriers in the recall domain. Conclusion: low and average adherence to drug therapy and the barrier related to the recall domain were associated with high risk of falls in the older adults.
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Ingvarsson S, Augustsson H, Hasson H, Nilsen P, von Thiele Schwarz U, von Knorring M. Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians. Implement Sci 2020; 15:93. [PMID: 33087154 PMCID: PMC7579796 DOI: 10.1186/s13012-020-01052-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Mia von Knorring
- Leadership in Healthcare and Academia Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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11
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Akande-Sholabi W, Ogundipe FS, Adisa R. Pharmacists' knowledge and counselling on fall risk increasing drugs in a tertiary teaching hospital in Nigeria. BMC Health Serv Res 2020; 20:259. [PMID: 32228567 PMCID: PMC7106790 DOI: 10.1186/s12913-020-05140-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Falls and fall-related injuries are a foremost health concern among older adults aged 60 years and above. Fall-risk-increasing drugs (FRIDs) use by older adults is one related cause of falling, and it is frequently used among older adults. Pharmacist-led counselling is an aspect of patient education that has been associated with improved therapeutic outcome and quality of life in high income countries with scarcity of information in low-middle income countries. This study therefore aims to assess hospital pharmacists' knowledge and counselling on fall-related medications using the list compiled by the Swedish National Board of Health and Welfare on FRIDs and orthostatic drugs (ODs). METHODS A cross-sectional survey was carried out among 56 pharmacists working in a teaching hospital in Nigeria, between July and August 2019, using a self-administered questionnaire. Data were summarized with descriptive statistics while chi-square test was used for categorical variables at p < 0.05. RESULTS Thirty-five (62.5%) were within 10 years of practice experience. Two-third (62.5%) of the pharmacists possessed an additional qualification to Bachelor of Pharmacy degree. Twenty-two (40.0%) were aware of the FRIDs and ODs list. In all, (89.3%) had "unsatisfactory" knowledge of classes of medications and specific medicines that could cause a fall. Most pharmacists 42 (80.8%) focused counsel on appropriate medication use, adverse effects of drugs and storage of medications. Knowledge score of both FRIDs and ODs were neither significantly associated with pharmacists' years of qualification (χ2 = 1.282; p = 0.733), (χ2 = 2.311; p = 0.510) nor with possession of additional qualification (χ2 = 0.854; p = 0.836), (χ2 = 2.996; p = 0.392). Majority, 53 (98.1%) believed that patients will benefit from effective counselling on FRIDs and ODs. About half (25; 51.0%) suggested training through seminar presentation as a measure for FRIDs and ODs sensitization. CONCLUSION A substantial gap in knowledge and awareness of FRIDs and ODs was noted among the hospital pharmacists. However, engagement of pharmacists on counsel that focus on medication use, adverse effect and storage was relatively better. Thus, there is a general need to create awareness about fall-risk-increasing drugs among hospital pharmacists, so as to help improve the therapeutic outcome particularly in the older adults.
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Affiliation(s)
- Wuraola Akande-Sholabi
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadana, Nigeria
| | - Francis S. Ogundipe
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadana, Nigeria
| | - Rasaq Adisa
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadana, Nigeria
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12
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Modification of Potentially Inappropriate Prescribing Following Fall-Related Hospitalizations in Older Adults. Drugs Aging 2019; 36:461-470. [PMID: 30834489 DOI: 10.1007/s40266-019-00646-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is strong evidence that potentially inappropriate prescribing is associated with falls in older adults. Fall-related hospitalizations should trigger medication review. OBJECTIVES The aim of this before-and-after cohort study was to explore patterns of relevant potentially inappropriate prescribing in older people with fall-related hospitalizations. METHODS Data on older adults with hospitalizations for falls, fractures and syncope between 2012 and 2016 were collected from 44 general practices in Ireland. Fall-related prescribing was defined from the Screening Tool for Older Persons' Prescriptions (sedatives and vasodilators) and the Screening Tool to Alert doctors to Right Treatment (vitamin D). Prevalence of prescriptions were estimated from general practice and hospital discharge records. Mixed-effects logistic regression was conducted to compare the 12-month pre- and post-hospitalization periods. RESULTS Overall, 927 individuals (68% female, average age 81.2 years; standard deviation 8.6) were included, 45% of whom had a diagnosis of fracture, 28% had syncope, and 27% had a fall without fracture/syncope. After adjustment for covariates and practice clustering effects, both vitamin D and sedatives had higher odds of prescription post-hospitalization (adjusted odds ratio [aOR] 4.47, 95% confidence interval [CI] 2.09-9.54, and aOR 1.75, 95% CI 1.29-2.39, respectively). With adjustments for age and sex, having a fracture was associated with new initiation of vitamin D (aOR 2.81, 95% CI 1.76-4.46) and having syncope was associated with continuing on vasodilators (aOR 1.99, 95% CI 1.06-3.74). No factors were associated with new sedative initiation. CONCLUSION Fall-related potentially inappropriate prescribing is prevalent in older adults who have a history of falls, and continues after discharge from hospital. Future studies should investigate why such prescribing is initiated after a fall-related hospitalization, and explore interventions that could reduce such hazardous prescribing.
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13
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Gillespie R, Mullan J, Harrison L. Deprescribing for older adults in Australia: factors influencing GPs. Aust J Prim Health 2019; 24:463-469. [PMID: 30423283 DOI: 10.1071/py18056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/17/2018] [Indexed: 12/24/2022]
Abstract
Polypharmacy is increasing among older Australians, raising their risk of experiencing medication-related harm. As part of the prescribing continuum, deprescribing is a strategy proposed to reduce inappropriate polypharmacy. This study explored factors that influence deprescribing among Australian GPs using a new 21-item survey to measure GP attitudes and practices. The 85 GP responses indicated that many factors are supportive of deprescribing. GPs suggest that they are willing to explore their older patients' deprescribing preferences; they believe that they have enough information about the potential harms and benefits of medication to inform their deprescribing decisions and are confident to communicate this information to their patients. GPs did not consider their patients would interpret deprescribing as being 'given up on'. Limited time to review medications, poor communication between prescribers and a perception that other prescribers do not respect their role as overall coordinators of their older patients' medications were considered by respondents to be unsupportive of deprescribing. Overall, despite GPs reporting many supportive factors for deprescribing, the influence of unsupportive factors appears to remain strong, as deprescribing is not routinely considered in practice.
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Affiliation(s)
- Robyn Gillespie
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Judy Mullan
- School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia
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14
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Tevik K, Selbæk G, Engedal K, Seim A, Krokstad S, Helvik AS. Factors associated with alcohol consumption and prescribed drugs with addiction potential among older women and men - the Nord-Trøndelag health study (HUNT2 and HUNT3), Norway, a population-based longitudinal study. BMC Geriatr 2019; 19:113. [PMID: 30999872 PMCID: PMC6472008 DOI: 10.1186/s12877-019-1114-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/24/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Little is known about factors associated with alcohol consumption and use of drugs with addiction potential in older adults. The aim of this study was to explore the association between socio-demographic variables, physical and mental health and the later (11 years) use of frequent drinking, prescribed drugs with addiction potential and the possible combination of frequent drinking and being prescribed drugs with addiction potential in older adults (≥ 65 years). METHODS In this longitudinal study, we used data from two surveys of the Nord-Trøndelag Health Study (HUNT2 1995-1997 and HUNT3 2006-2008), a population based study in Norway. We totally included 10,656 individuals (5683 women) aged 54 years and older when they participated in HUNT2. Frequent drinking was defined as drinking alcohol 4 days or more per week. Data on prescribed drugs with addiction potential were drawn from the Norwegian Prescription Database. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009. RESULTS The typical frequent drinker in HUNT3 was younger, more educated, lived in urban areas, and reported smoking and drinking frequently in HUNT2 compared to the non-frequent drinker in HUNT3. The typical user of prescribed drugs with addiction potential in HUNT3 was an older woman who smoked and was in poor health, suffered from anxiety, had been hospitalized in the last 5 years and used anxiety or sleep medication every week or more often in HUNT2. The typical individual in HUNT3 with the possible combination of frequent drinking and being prescribed drugs with addiction potential had more education, smoked, drank frequently and used anxiety or sleep medication in HUNT2. CONCLUSION Individuals who were identified as frequent drinkers in HUNT2 were more likely to be frequent drinkers in HUNT3, and to have the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3. Health care professionals need to be aware of use of alcohol among older adults using drugs with addiction potential.
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Affiliation(s)
- Kjerstin Tevik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- The Research Centre for Age-related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Arnfinn Seim
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Steinar Krokstad
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, (NTNU), Levanger, Norway
- Psychiatric Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Anne-S Helvik
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olavs University Hospital, Sluppen, Trondheim, Norway
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15
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Seppala LJ, van der Velde N, Masud T, Blain H, Petrovic M, van der Cammen TJ, Szczerbińska K, Hartikainen S, Kenny RA, Ryg J, Eklund P, Topinková E, Mair A, Laflamme L, Thaler H, Bahat G, Gutiérrez-Valencia M, Caballero-Mora MA, Landi F, Emmelot-Vonk MH, Cherubini A, Baeyens JP, Correa-Pérez A, Gudmundsson A, Marengoni A, O'Mahony D, Parekh N, Pisa FE, Rajkumar C, Wehling M, Ziere G. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Eur Geriatr Med 2019; 10:275-283. [PMID: 34652762 DOI: 10.1007/s41999-019-00162-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.
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Affiliation(s)
- L J Seppala
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - T Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - H Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, Montpellier University, Euromov, France
| | - M Petrovic
- Department of Internal Medicine (Geriatrics), Ghent University, Ghent, Belgium
| | - T J van der Cammen
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - S Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - R A Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland.,Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - J Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P Eklund
- Department of Computing Science, Umeå University, Umeå, Sweden
| | - E Topinková
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic.,Faculty of Health and Social Sciences, South Bohemian University, Česke Budějovice, Czech Republic
| | - A Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - L Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Widerströmska huset, 17177, Stockholm, Sweden
| | - H Thaler
- Trauma Center Wien-Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - G Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - M Gutiérrez-Valencia
- Department of Health Sciences, Public University of Navarra (UPNA), Avda, Barañain s/n, 31008, Pamplona, Spain
| | - M A Caballero-Mora
- Servicio de Geriatría, Hospital Universitario de Getafe and CIBER de Fragilidad y Envejecimiento Saludable, Getafe, Madrid, Spain
| | - F Landi
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - A Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'Invecchiamento, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - J P Baeyens
- University of Luxembourg, Ezch-sur-Alzette, Luxembourg.,AZ Alma, Eeklo, Belgium
| | - A Correa-Pérez
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - A Gudmundsson
- Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - A Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - D O'Mahony
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland.,Department of Medicine, University College Cork, Cork, Ireland
| | - N Parekh
- Academic Department of Geriatric Medicine, Brighton and Sussex Medical School, Brighton, Sussex, UK
| | - F E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - C Rajkumar
- Department of Elderly Medicine, Brighton and Sussex University Hospitals NHS Trust, Sussex, UK
| | - M Wehling
- Institute of Clinical Pharmacology Mannheim, University of Heidelberg, Heidelberg, Germany
| | - G Ziere
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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16
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Seppala LJ, van der Velde N, Masud T, Blain H, Petrovic M, van der Cammen TJ, Szczerbińska K, Hartikainen S, Kenny RA, Ryg J, Eklund P, Topinková E, Mair A, Laflamme L, Thaler H, Bahat G, Gutiérrez-Valencia M, Caballero-Mora MA, Landi F, Emmelot-Vonk MH, Cherubini A, Baeyens JP, Correa-Pérez A, Gudmundsson A, Marengoni A, O'Mahony D, Parekh N, Pisa FE, Rajkumar C, Wehling M, Ziere G. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Drugs Aging 2019; 36:299-307. [PMID: 30741371 PMCID: PMC6435622 DOI: 10.1007/s40266-018-0622-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.
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Affiliation(s)
- L J Seppala
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - T Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - H Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, Montpellier University, Euromov, France
| | - M Petrovic
- Department of Internal Medicine (Geriatrics), Ghent University, Ghent, Belgium
| | - T J van der Cammen
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - S Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - R A Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - J Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P Eklund
- Department of Computing Science, Umeå University, Umeå, Sweden
| | - E Topinková
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Faculty of Health and Social Sciences, South Bohemian University, Česke Budějovice, Czech Republic
| | - A Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - L Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Widerströmska huset, 17177, Stockholm, Sweden
| | - H Thaler
- Trauma Center Wien-Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - G Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - M Gutiérrez-Valencia
- Department of Health Sciences, Public University of Navarra (UPNA), Avda, Barañain s/n, 31008, Pamplona, Spain
| | - M A Caballero-Mora
- Servicio de Geriatría, Hospital Universitario de Getafe and CIBER de Fragilidad y Envejecimiento Saludable, Getafe, Madrid, Spain
| | - F Landi
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'Invecchiamento, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - J P Baeyens
- University of Luxembourg, Ezch-sur-Alzette, Luxembourg
- AZ Alma, Eeklo, Belgium
| | - A Correa-Pérez
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - A Gudmundsson
- Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - A Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - D O'Mahony
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, University College Cork, Cork, Ireland
| | - N Parekh
- Academic Department of Geriatric Medicine, Brighton and Sussex Medical School, Brighton, Sussex, UK
| | - F E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
- Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - C Rajkumar
- Department of Elderly Medicine, Brighton and Sussex University Hospitals NHS Trust, Sussex, UK
| | - M Wehling
- Institute of Clinical Pharmacology Mannheim, University of Heidelberg, Heidelberg, Germany
| | - G Ziere
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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17
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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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18
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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Sundseth AC, Gjelstad S, Straand J, Rosvold EO. General practitioners' prescriptions of benzodiazepines, Z-hypnotics and opioid analgesics for elderly patients during direct and indirect contacts. A cross-sectional, observational study. Scand J Prim Health Care 2018; 36:115-122. [PMID: 29656692 PMCID: PMC6066290 DOI: 10.1080/02813432.2018.1459164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe Norwegian general practitioners' (GPs') prescription patterns of benzodiazepines, Z-hypnotics and opioid analgesics (BZO-drugs) to elderly (≥70 years) patients. DESIGN, SUBJECTS AND SETTING Cross sectional, observational study. Contact- and prescription data from 148 Norwegian GPs, issued for elderly patients during eight months in 2008. GP-patient contacts were categorized as direct contacts (DC: face-to-face consultations) or indirect contacts (IC: via third party, phone or mail). Explanatory variables were characteristics linked to the GPs, patients, and practices. During analyses, GPs' number of listed patients, share of which for elderly patients, and total number of patient consultations during the period (proxy for practice activity), were categorized in quintiles (Q1-5) by number of GPs. MAIN OUTCOME MEASURES Number of BZO-drug prescriptions and quantities issued during direct- and indirect GP-patient contacts. RESULTS In total, 62% of BZO-prescriptions were issued during ICs. Of all prescriptions, 66% were large quantum packages (50 tablets or more), 62% out of which were prescribed during ICs. During the study period, 50% of the patients received repeat prescriptions. Prescribing during ICs was associated with low over all practice activity (Q1) and many (Q5) older patients on the GP's lists. CONCLUSION GPs' BZO-drug prescribing to elderly occur more frequently during ICs than within DCs, and are more commonly issued as large quantity packages. This indicates that regular- or long-term use among elderly is common, contrasting with previous and current national guidelines, which recommend regular clinical assessments and short time or intermittent use of BZO-drugs. Key Points GPs frequently prescribe benzodiazepines, Z-hypnotics and opioid (BZO) drugs for elderly people. BZO-drugs are frequently issued during indirect GP-patient contacts and in relatively large quantities, indicating regular or long-term use. GPs' BZO-drug prescribing patterns contrast with national guidelines recommending clinical assessment and short time or intermittent use of BZO-drugs.
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Affiliation(s)
- Anne Cathrine Sundseth
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
- CONTACT Anne Cathrine SundsethDepartment of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
| | - Jorund Straand
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
- General Practice Research Unit, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Elin O. Rosvold
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
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Musich S, Wang SS, Ruiz J, Hawkins K, Wicker E. Falls-Related Drug Use and Risk of Falls Among Older Adults: A Study in a US Medicare Population. Drugs Aging 2017; 34:555-565. [PMID: 28580498 PMCID: PMC5488077 DOI: 10.1007/s40266-017-0470-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Approximately one-third of community-dwelling older adults fall each year, and approximately 10% have falls requiring medical services. Among other factors, research studies have linked certain medications with an increased risk of falls. Objective The aim of this study was to examine the risk of falls relative to use patterns among new and continuing falls-related drug (FRD) users. Methods A 10% random sample, insured in AARP® Medicare Supplement and AARP Medicare Part D Rx plans, was utilized to define new and continuing FRD users. New users had a 12-month pre-period without FRD use, whereas continuing users had at least one FRD in the pre-period. Both groups had 12-month follow-up after initiating or continuing FRD use. Characteristics associated with the risk of falls for new and continuing users were determined using multivariate logistic regression models. Results Among insureds, 44% used at least one of the FRD classes. Of these, 29% were new users (N = 35,340) and 71% were continuing users (N = 121,488). Fall rates for the two subgroups were similar at 7 and 8%, respectively. Characteristics associated with the risk of falls were previous injurious fall, use of two or more classes of FRDs, older age, poorer health, and being female. New users were at higher risk than continuing users. Conclusion New users of FRDs were at highest risk of falls, and continuing users were at increased risk, especially with higher numbers of FRD classes. Both groups could benefit from falls awareness and prevention programs.
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Affiliation(s)
- Shirley Musich
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA.
| | - Shaohung S Wang
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA
| | - Joann Ruiz
- Medicare and Retirement, UnitedHealthcare Alliances, PO Box 9472, Minneapolis, MN, 55440, USA
| | - Kevin Hawkins
- Advanced Analytics, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI, 48108, USA
| | - Ellen Wicker
- , 601 E. Street, N.W., Washington, DC, 20049, USA
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Bell HT, Steinsbekk A, Granas AG. Elderly users of fall-risk-increasing drug perceptions of fall risk and the relation to their drug use - a qualitative study. Scand J Prim Health Care 2017; 35:247-255. [PMID: 28793815 PMCID: PMC5592351 DOI: 10.1080/02813432.2017.1358438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The aim of the study was to explore how home-dwelling elderly who use fall-risk-increasing drugs (FRIDs) perceive their fall risk and how they relate this to their drug use. DESIGN, SETTING AND SUBJECTS A qualitative study with 14 home-dwelling elderly FRID users between 65 and 97 years in Central Norway participating in semi-structured individual interviews. The data were analyzed thematically by using systematic text condensation. RESULTS The main finding was that the informants did not necessarily perceive the use of FRIDs to be a prominent risk factor for falls. Some informants said they did not reflect upon drug use whatsoever and said they fully trusted their physician's choices. When either experiencing dizziness, fall episodes or by reading the patient information leaflet the informants said to either adjust their drug use or to contact their physician. Some felt rejected due to not getting their point across or their wish to alter the drug was not granted by the physician. CONCLUSIONS Elderly FRID users did not necessarily relate their drug use to fall risk or struggled to present their perceived drug-related problems. Physicians need to regularly inform, monitor and assess the drug treatment when treating elderly with FRIDs.
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Affiliation(s)
- Hege Therese Bell
- Department of Pharmacy, Faculty of Health Sciences, Nord University, Namsos, Norway
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
- CONTACT Hege Therese Bell Skjermvegen 60a, 7023 Trondheim, Norway
| | - Aslak Steinsbekk
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
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Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention. Implement Sci 2017; 12:71. [PMID: 28549480 PMCID: PMC5446684 DOI: 10.1186/s13012-017-0602-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/16/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing. METHODS Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement. RESULTS No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication. CONCLUSIONS Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease. TRIAL REGISTRATION ClinicalTrials.gov, NCT02604056.
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Bell HT, Granas AG, Enmarker I, Omli R, Steinsbekk A. Nurses' and pharmacists' learning experiences from participating in interprofessional medication reviews for elderly in primary health care - a qualitative study. BMC FAMILY PRACTICE 2017; 18:30. [PMID: 28241789 PMCID: PMC5330158 DOI: 10.1186/s12875-017-0598-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 02/09/2017] [Indexed: 11/28/2022]
Abstract
Background Traditionally, drug prescription and follow up have been the sole responsibility of physicians. However, interprofessional medication reviews (IMRs) have been developed to prevent drug discrepancies and patient harm especially for elderly patients with polypharmacy and multimorbidity. What participating nurses and pharmacists learn from each other during IMR is poorly studied. The aim of this study was to investigate nurses’ and pharmacists’ perceived learning experience after participating in IMRs in primary health care for up to two years. Methods A qualitative study with semi-structured focus group interviews and telephone interviews with nurses and pharmacists with experience from IMRs in nursing homes and home based services. The data was analysed thematically by using systematic text condensation. Results Thirteen nurses and four pharmacists were interviewed. They described some challenges concerning how to ensure participation of all three professions and how to get thorough information about the patient. As expected, both professions talked of an increased awareness with time of the benefit of working as a team and the perception of contributing to better and more individual care. The nurses’ perception of the pharmacist changed from being a controller of drug management routines towards being a source of pharmacotherapy knowledge and a discussant partner of appropriate drug therapy in the elderly. The pharmacists became more aware of the nurses’ crucial role of providing clinical information about the patient to enable individual advice. Increasingly the nurses learned to link the patient’s symptoms of effect and side effect to the drugs prescribed. Conclusions Although experiencing challenges in conducting IMRs, the nurses and pharmacists had learning experiences they said improved both their own practice and the quality of drug management. There are some challenges concerning how to ensure participation of all three professions and how to get thorough information about the patient. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0598-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- H T Bell
- Department of Pharmacy, Faculty of Health Sciences, Nord University, Namsos, Norway. .,Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
| | - A G Granas
- School of Pharmacy, University of Oslo, Oslo, Norway
| | - I Enmarker
- Centre for Care research Mid- Norway, Steinkjer, Norway.,Department of Nursing, Mid University, Østersund, Sweden
| | - R Omli
- Department of Pharmacy, Faculty of Health Sciences, Nord University, Namsos, Norway.,Centre for Care research Mid- Norway, Steinkjer, Norway
| | - A Steinsbekk
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
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Stam H, Harting T, van der Sluijs M, van Marum R, van der Horst H, van der Wouden JC, Maarsingh OR. Usual care and management of fall risk increasing drugs in older dizzy patients in Dutch general practice. Scand J Prim Health Care 2016; 34:165-71. [PMID: 27049170 PMCID: PMC4977939 DOI: 10.3109/02813432.2016.1160634] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE For general practitioners (GPs) dizziness is a challenging condition to deal with. Data on the management of dizziness in older patients are mostly lacking. Furthermore, it is unknown whether GPs attempt to decrease Fall Risk Increasing Drugs (FRIDs) use in the management of dizziness in older patients. The aim of this study is to gain more insight into GP's management of dizziness in older patients, including FRID evaluation and adjustment. DESIGN Data were derived from electronic medical records, obtained over a 12-month period in 2013. SETTING Forty-six Dutch general practices. PATIENTS The study sample comprised of 2812 older dizzy patients of 65 years and over. Patients were identified using International Classification of Primary Care codes and free text. MAIN OUTCOME MEASURES Usual care was categorized into wait-and-see strategy (no treatment initiated); education and advice; additional testing; medication adjustment; and referral. RESULTS Frequently applied treatments included a wait-and-see strategy (28.4%) and education and advice (28.0%). Additional testing was performed in 26.8%; 19.0% of the patients were referred. Of the patients 87.2% had at least one FRID prescription. During the observation period, GPs adjusted the use of one or more FRIDs for 11.7% of the patients. CONCLUSION This study revealed a wide variety in management strategies for dizziness in older adults. The referral rate for dizziness was high compared to prior research. Although many older dizzy patients use at least one FRID, FRID evaluation and adjustment is scarce. We expect that more FRID adjustments may reduce dizziness and dizziness-related impairment. Key Points It is important to know how general practitioners manage dizziness in older patients in order to assess potential cues for improvement. This study revealed a wide variety in management strategies for dizziness in older patients. There was a scarcity in Fall Risk Increasing Drug (FRID) evaluation and adjustment. The referral rate for dizziness was high compared with previous research.
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Affiliation(s)
- Hanneke Stam
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
- CONTACT Hanneke Stam, MD VU University Medical Center, Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Thomas Harting
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
| | - Marjolijn van der Sluijs
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
| | - Rob van Marum
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Henriëtte van der Horst
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
| | - Johannes C. van der Wouden
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
| | - Otto R. Maarsingh
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands;
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Linn HI. The Changed Injury Landscape, More on Injury Prevention Roles for the Lifestyle Physician, and More Than "Limited Progress" Since Injury in America. Am J Lifestyle Med 2016; 10:10-13. [PMID: 30202253 PMCID: PMC6124863 DOI: 10.1177/1559827615609032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
One theme of the article ("Time for Lifestyle Medicine to Take Injury Prevention Seriously," by Teitge and Francescutti) that should resonate with contemporary injury prevention proponents-whether they are researchers, practitioners, policy makers, or advocates in the public health arena or providers, administrators, and patient advocates in the health care arena-is the need for an increased injury prevention focus among health care providers. In particular, the call for providers to link injury prevention approaches and tools to the clinical care of patients is both noteworthy and compelling. However, the authors' description of the current injury experience in the United States fails to acknowledge important changes over the past decade and a half that have had an impact on the injury prevention roles of providers. Plus, the notion that progress in injury prevention has been limited in the 3 decades since the publication of Injury in America, undervalues the advances that have occurred.
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Affiliation(s)
- Herbert I. Linn
- Injury Control Research Center, West Virginia University, Morgantown, West Virginia
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