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Vordenberg SE, Rana R, Shang J, Choi J, Scherer AM, Weir KR. Reasons why older adults in three countries agreed with a deprescribing recommendation in a hypothetical vignette. Basic Clin Pharmacol Toxicol 2023; 133:673-682. [PMID: 36894739 DOI: 10.1111/bcpt.13857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023]
Abstract
The purpose of this study was to examine factors important to older adults who agreed with a deprescribing recommendation given by a general practitioner (GP) to a hypothetical patient experiencing polypharmacy. We conducted an online, vignette-based, experimental study in the United Kingdom, United States and Australia with participants ≥65 years. The primary outcome was an agreement with a deprescribing recommendation (6-point Likert scale; 1 = strongly disagree and 6 = strongly agree). We performed a content analysis of the free-text reasons provided by participants who agreed with deprescribing (score of 5 or 6). Among 2656 participants who agreed with deprescribing, approximately 53.7% shared a preference for following the GP's recommendation or considered the GP the expert. The medication was referred to as a reason for deprescribing by 35.6% of participants. Less common themes included personal experience with medicine (4.3%) and older age (4.0%). Older adults who agreed with deprescribing in a hypothetical vignette most frequently reported a desire to follow the recommendations given the GP's expertise. Future research should be conducted to help clinicians efficiently identify patients who have a strong desire to follow the doctor's recommendations related to deprescribing, as this may allow for a tailored, brief deprescribing conversation.
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Affiliation(s)
- Sarah E Vordenberg
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- University of Michigan Center for Bioethics and Social Sciences in Medicine, 28000 Plymouth Rd, Ann Arbor, MI 48019, Michigan, USA
| | - Ruchi Rana
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Jenny Shang
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Jae Choi
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aaron M Scherer
- University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, Iowa, USA
| | - Kristie Rebecca Weir
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
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Bortolussi-Courval É, Podymow T, Trinh E, Moryousef J, Hanula R, Huon JF, Mavrakanas T, Suri R, Lee TC, McDonald EG. Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study. Can J Kidney Health Dis 2023; 10:20543581231165712. [PMID: 37435299 PMCID: PMC10331104 DOI: 10.1177/20543581231165712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/13/2023] [Indexed: 07/13/2023] Open
Abstract
Background Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Objectives Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. Design This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. Setting The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. Patients A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. Measurements We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. Methods The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Limitations Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Conclusions Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. Trial registration This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.
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Affiliation(s)
- Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Tiina Podymow
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Emilie Trinh
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Joseph Moryousef
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - R. Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Jean-François Huon
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Thomas Mavrakanas
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Todd C. Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Emily Gibson McDonald
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Montreal, QC, Canada
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Vordenberg SE, Weir KR, Jansen J, Todd A, Schoenborn N, Scherer AM. Harm and Medication-Type Impact Agreement with Hypothetical Deprescribing Recommendations: a Vignette-Based Experiment with Older Adults Across Four Countries. J Gen Intern Med 2023; 38:1439-1448. [PMID: 36376636 PMCID: PMC10160278 DOI: 10.1007/s11606-022-07850-5] [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: 05/16/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about what factors are important to older adults when deciding whether to agree with a recommendation to deprescribe. OBJECTIVE To explore the extent to which medication type and rationale for potential discontinuation influence older adults' acceptance of deprescribing. DESIGN Cross-sectional 2 (drug: lansoprazole - treat indigestion; simvastatin - prevent cardiovascular disease) by 3 (deprescribing rationale: lack of benefit; potential for harm; both) experimental design. PARTICIPANTS Online panelists aged ≥65 years from Australia, the Netherlands, the United Kingdom, and the United States INTERVENTIONS: Participants were presented with a hypothetical patient experiencing polypharmacy whose PCP discussed stopping a medication. We randomized participants to receive one of six vignettes. MAIN MEASURES We measured agreement with deprescribing (6-point Likert scale, "Strongly disagree (1)" and "Strongly agree (6)") for the hypothetical patient as the primary outcome. We also measured participants' personality traits, perceptions of risk and uncertainty, and attitudes towards polypharmacy and deprescribing. KEY RESULTS Among 5311 participants (93.3% completion rate), the mean (M) agreement with deprescribing for the hypothetical patient was 4.71 (95% confidence interval (CI): 4.67, 4.75). Participants reported higher agreement with stopping lansoprazole (n=2656) (M=4.90, 95% CI: 4.85, 4.95) compared to simvastatin (n=2655) (M=4.53, 95% CI: 4.47, 4.58), P<.001. Participants who received the combination rationale (n=1786) reported higher agreement with deprescribing (M=4.83, 95% CI: 4.76, 4.89) compared to those who received the rationales on lack of benefit (n=1755) (M=4.66, 95% CI: 4.60, 4.73) or potential for harm (n=1770) (M=4.65, 95% CI 4.58, 4.72). In adjusted regression analyses (n=5062), participants with a higher desire to engage in health promotion behaviors (b=0.08, 95% CI 0.02, 0.13) or need for certainty (b=0.12, 95% CI 0.04, 0.20) reported higher agreement with deprescribing. CONCLUSIONS Older adults across four countries were accepting of deprescribing in the setting of polypharmacy. The medication type and rationale for discontinuation were important factors in the decision-making process. TRIAL REGISTRATION ClinicalTrials.gov , NCT04676282, https://clinicaltrials.gov/ct2/show/NCT04676282?term=vordenberg&draw=2&rank=1.
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Affiliation(s)
- Sarah E Vordenberg
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church St, 3563 NUB, Ann Arbor, MI, 48109, USA.
| | - Kristie Rebecca Weir
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Adam Todd
- Newcastle University School of Pharmacy, Newcastle upon Tyne, UK
| | | | - Aaron M Scherer
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population. Geriatrics (Basel) 2022; 7:geriatrics7050097. [PMID: 36136806 PMCID: PMC9498769 DOI: 10.3390/geriatrics7050097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.
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Assessing Potentially Inappropriate Medications in Nursing Home Residents by NORGEP-NH Criteria. PHARMACY 2019; 7:pharmacy7010026. [PMID: 30841495 PMCID: PMC6473407 DOI: 10.3390/pharmacy7010026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Nursing home residents often have several conditions that necessitate the use of multiple medicines. This study investigates the prevalence of potentially inappropriate medications (PIMs) and its associations with sex, age, number of medicines, and study location (rural/urban). Methods: A cross-sectional study of long-term care residents from six nursing homes. Data was collected from medical records. We identified PIMs by applying the NORGEP-NH criteria. We conducted a Poisson regression analysis to investigate the association between the number of PIMs and sex, age, number of medicines, and study location. Results: We included 103 (18.4%) of 559 residents (68.0% women; mean age 83.2 years, mean number of daily used medicines 7.2 (SD = 3.6)). We identified PIMs in 56% of the residents (mean number = 1.10, SD = 1.26). In adjusted analyses, residents ≥80 years had 0.43 fewer PIMs compared to residents <80 years (p < 0.05). Residents using 4–6, 7–9, and 10+ medicines had on average 0.73, 1.06, and 2.11 more PIMs compared to residents using 0–3 medicines (p < 0.001), respectively. Conclusion: PIM use is prevalent among nursing home residents and is significantly associated with age and number of medicines. Our findings suggest a modest decrease in residents using PIMs compared to previous studies. Nevertheless, prescribing quality in nursing home residents in both urban and rural areas is still of great concern.
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