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Chiu YM, Sirois C, Simard M, Gagnon ME, Talbot D. Traditional Methods Hold Their Ground Against Machine Learning in Predicting Potentially Inappropriate Medication Use in Older Adults. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1393-1399. [PMID: 38977181 DOI: 10.1016/j.jval.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/30/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES Machine learning methods have gained much attention in health sciences for predicting various health outcomes but are scarcely used in pharmacoepidemiology. The ability to identify predictors of suboptimal medication use is essential for conducting interventions aimed at improving medication outcomes. It remains uncertain whether machine learning methods could enhance the identification of potentially inappropriate medication use among older adults compared with traditional methods. This study aimed to (1) to compare the performances of machine learning models in predicting use of potentially inappropriate medications and (2) to quantify and compare the relative importance of predictors in a population of community-dwelling older adults (>65 years) in the province of Québec, Canada. METHODS We used the Québec Integrated Chronic Disease Surveillance System and selected a cohort of 1 105 295 older adults of whom 533 719 were potentially inappropriate medication users. Potentially inappropriate medications were defined according to the Beers list. We compared performances between 5 popular machine learning models (gradient boosting machines, logistic regression, naive Bayes, neural networks, and random forests) based on receiver operating characteristic curves and other performance criteria, using a set of sociodemographic and medical predictors. RESULTS No model clearly outperformed the others. All models except neural networks were in agreement regarding the top predictors (sex and anxiety-depressive disorders and schizophrenia) and the bottom predictors (rurality and social and material deprivation indices). CONCLUSIONS Including other types of predictors (eg, unstructured data) may be more useful for increasing performance in prediction of potentially inappropriate medication use.
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Affiliation(s)
- Yohann Moanahere Chiu
- Faculté de pharmacie, Université Laval, Québec, QC, Canada; Institut national de santé publique du Québec, Québec, QC, Canada; VITAM-Centre de recherche en santé durable, Centre intégré de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada.
| | - Caroline Sirois
- Faculté de pharmacie, Université Laval, Québec, QC, Canada; Institut national de santé publique du Québec, Québec, QC, Canada; VITAM-Centre de recherche en santé durable, Centre intégré de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Marc Simard
- Institut national de santé publique du Québec, Québec, QC, Canada; VITAM-Centre de recherche en santé durable, Centre intégré de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada; Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Marie-Eve Gagnon
- Faculté de pharmacie, Université Laval, Québec, QC, Canada; VITAM-Centre de recherche en santé durable, Centre intégré de santé et de services sociaux de la Capitale Nationale, Québec, QC, Canada; Département des Sciences de la Santé, Université du Québec à Rimouski, Québec, QC, Canada
| | - Denis Talbot
- Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
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Huon JF, Sanyal C, Gagnon CL, Turner JP, Khuong NB, Bortolussi-Courval É, Lee TC, Silvius JL, Morgan SG, McDonald EG. The cost of potentially inappropriate medications for older adults in Canada: A comparative cross-sectional study. J Am Geriatr Soc 2024. [PMID: 39235969 DOI: 10.1111/jgs.19164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 07/22/2024] [Accepted: 07/30/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described. METHODS This was a cross-sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation-adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$. RESULTS Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021). CONCLUSIONS While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed.
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Affiliation(s)
- Jean-François Huon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Nantes Université, CHU Nantes, Pharmacie, Nantes, France
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Chiranjeev Sanyal
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Camille L Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
| | - Justin P Turner
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Center for Medicine Use and Safety, Monash University, Clayton, Victoria, Australia
| | - Ninh B Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - James L Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily G McDonald
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
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Staples JA, Yu Y, Khan M, Naik H, Liu G, Brubacher JR, Karimuddin A, Sutherland JM. Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: A Propensity Score Weighted Cohort Study. Am J Med 2024; 137:847-856.e11. [PMID: 38750712 DOI: 10.1016/j.amjmed.2024.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/15/2024] [Accepted: 04/28/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Unplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk. METHODS In 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the "G78717" fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all nonelective hospitalizations potentially eligible for the incentive over a 5-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients. RESULTS A total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95% CI, 0.93-1.01; P = .23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95% CI, 0.95-1.05; P = .93). CONCLUSIONS A physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere. TRIAL REGISTRATION ClinicalTrials.gov ID, NCT03256734.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada; Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.
| | - Ying Yu
- Department of Medicine, University of British Columbia, Vancouver, Canada.
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Hiten Naik
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Ahmer Karimuddin
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
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Ayalew MB, Dieberg G, Quirk F, Spark MJ. Assessment of Potentially Inappropriate Prescribing for People With Type 2 Diabetes Mellitus Using IMPACT2DM, a New Explicit Tool. J Pharm Pract 2024; 37:546-556. [PMID: 36525968 DOI: 10.1177/08971900221145219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background: People with type 2 diabetes mellitus (T2DM) are at greater risk of potentially inappropriate prescribing (PIP) due to multiple comorbidities and polypharmacy. IMPACT2DM (Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus) is a tool designed to identify PIP for adults with T2DM. Objectives: To assess PIP for adults with T2DM in Ethiopia using the IMPACT2DM and to test the face validity and clinical validity of the tool. Methods: A cross-sectional study was undertaken using data extracted retrospectively from the medical records of adults being managed for T2DM at Debretabore Hospital. PIP was assessed using IMPACT2DM. Some items/item components of IMPACT2DM were modified to increase the tool's applicability for the outpatient setting, to clarify content or to use the terms most common in this particular setting. Multivariant logistic regression analyses were conducted to identify factors associated with PIP. Results: More than 90% of medical records had at least 1 PIP. Prescribing omission (80.9%) was the most commonly identified type of PIP. Adults with prescribing omissions are more likely to be ≥40 years old or to be prescribed with <5 medications. Adults with dosing problems were more likely ≥50 years old, or have had a fasting blood sugar (FBS) level out of the target range (80-130 mg/dL). Conclusions: IMPACT2DM is a clinically valid PIP identification tool for application in an Ethiopian outpatient setting. Health professionals should be alert to check for potential prescribing omissions for adults ≥40 years old and dosing problems for adults with an FBS level out of the target range or >50 years.
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Affiliation(s)
- Mohammed B Ayalew
- Pharmacy, School of Rural Medicine, University of New England, Armidale, NSW, Australia
- Department of Clinical Pharmacy, School of Pharmacy, University of Gondar, Gondar, Ethiopia
| | - Gudrun Dieberg
- Biomedical Science, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Frances Quirk
- School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | - Marion J Spark
- Pharmacy, School of Rural Medicine, University of New England, Armidale, NSW, Australia
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Daunt R, Curtin D, O'Mahony D. Optimizing drug therapy for older adults: shifting away from problematic polypharmacy. Expert Opin Pharmacother 2024; 25:1199-1208. [PMID: 38940370 DOI: 10.1080/14656566.2024.2374048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/25/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION The accelerated discovery and production of pharmaceutical products has resulted in many positive outcomes. However, this progress has also contributed to problematic polypharmacy, one of the rapidly growing threats to public health in this century. Problematic polypharmacy results in adverse patient outcomes and imposes increased strain and financial burden on healthcare systems. AREAS COVERED A review was conducted on the current body of evidence concerning factors contributing to and consequences of problematic polypharmacy. Recent trials investigating interventions that target polypharmacy and emerging solutions, including incorporation of artificial intelligence, are also examined in this article. EXPERT OPINION To shift away from problematic polypharmacy, a multifaceted interdisciplinary approach is necessary. Any potentially successful strategy must be adapted to suit various healthcare settings and must utilize all available resources, including artificial intelligence.
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Affiliation(s)
- Ruth Daunt
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Denis Curtin
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Denis O'Mahony
- Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
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Rodrigues RC, Gomes GKA, Sodré BMC, Lima RF, Barros DSL, Figueiredo ACMG, Stefani CM, Silva DLMD. Lists of potentially inappropriate medications for older people in primary care: a systematic review of health outcomes. CAD SAUDE PUBLICA 2024; 40:e00016423. [PMID: 38775606 PMCID: PMC11111166 DOI: 10.1590/0102-311xen016423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 05/24/2024] Open
Abstract
This study is a systematic literature review of the association between lists of potentially inappropriate medications (PIM) in clinical practice and health outcomes of older adults followed up in primary health care. For this purpose, the PRISMA protocol was used to systematize the search for articles in the PubMed, Web of Science, Scopus, Cochrane Central, LIVIVO and LILACS databases, in addition to the gray literature. Studies with randomized clinical trials were selected, using explicit criteria (lists) for the identification and management of PIM in prescriptions of older patients in primary care. Of the 2,400 articles found, six were used for data extraction. The interventions resulted in significant reductions in the number of PIM and adverse drug events and, consequently, in potentially inappropriate prescriptions (PIP) in polymedicated older adults. However, there were no significant effects of the interventions on negative clinical outcomes, such as emergency room visits, hospitalizations and death, or on improving the health status of the older adults. The use of PIM lists promotes adequate medication prescriptions for older adults in primary health care, but further studies are needed to determine the impact of reducing PIM on primary clinical outcomes.
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McDonald EG, Lundby C, Thompson W, Boyd C, Farrell B, Gagnon C, Herbin J, Khuong N, Moriarty F, Pierson T, Scott S, Scott IA, Silvius J, Spinewine A, Steinman MA, Tannenbaum C, Trimble J, Turner JP, Reeve E. Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks. Expert Rev Clin Pharmacol 2024; 17:433-440. [PMID: 38739460 DOI: 10.1080/17512433.2024.2355270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology in the School of Medicine, the Center on Aging and Health, and the departments of Epidemiology and Health Policy and Management at Johns Hopkins University in Baltimore, Baltimore, MD, USA
| | - Barbara Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Jennie Herbin
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tiphaine Pierson
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian A Scott
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jim Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Provincial Seniors Health & Continuing Care, Alberta Health Services, Alberta, Canada
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group UCLouvain, Brussels, Belgium
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Cara Tannenbaum
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Johanna Trimble
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Melbourne, SA, Australia
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Bose S, Groat D, Stollings JL, Barney P, Dinglas VD, Goodspeed VM, Carmichael H, Mir-Kasimov M, Jackson JC, Needham DM, Brown SM, Sevin CM. Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure. Aust Crit Care 2024:S1036-7314(24)00030-4. [PMID: 38688808 DOI: 10.1016/j.aucc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue. RESEARCH QUESTION The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge. STUDY DESIGN AND METHODS Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis. RESULTS Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32). CONCLUSION At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation.
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Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Danielle Groat
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Patrick Barney
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Valerie M Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Harris Carmichael
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Mustafa Mir-Kasimov
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA; Section of Pulmonary and Critical Care Medicine, George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, and Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Samuel M Brown
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carla M Sevin
- Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Holbrook A, Perri D, Levine M, Mbuagbaw L, Jarmain S, Thabane L, Tarride JE, Dolovich L, Hyland S, Telford V, Silva J, Nieuwstraten C. Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol. Pilot Feasibility Stud 2024; 10:60. [PMID: 38600599 PMCID: PMC11005201 DOI: 10.1186/s40814-024-01484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group. METHODS The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge. DISCUSSION If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04077281.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.
| | - Dan Perri
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Digital Solutions, St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mitch Levine
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Sarah Jarmain
- Medical and Academic Affairs, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Center for Health Economic and Policy Analysis, McMaster University, Hamilton, ON, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, ON, Canada
| | - Victoria Telford
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
| | - Jessyca Silva
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, ON, Canada
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10
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Al Meslamani AZ, Jarab AS. The economic impact of pharmacist intervention during pandemics. Expert Rev Pharmacoecon Outcomes Res 2024; 24:323-326. [PMID: 37993404 DOI: 10.1080/14737167.2023.2287487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Ahmad Z Al Meslamani
- College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
| | - Anan S Jarab
- College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
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11
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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12
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Nigussie S, Demeke F. Potentially Inappropriate Medications Use and Associated Factors Among Older Patients on Follow-Up at the Chronic Care Clinic of Hiwot Fana Comprehensive Specialized Hospital in Eastern Ethiopia. CURRENT THERAPEUTIC RESEARCH 2023; 100:100730. [PMID: 38362229 PMCID: PMC10867584 DOI: 10.1016/j.curtheres.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/17/2023] [Indexed: 02/17/2024]
Abstract
Background Potentially inappropriate medications (PIMs) use often cause to poor health outcomes in older patients. There is a dearth of information on PIMS use in this population of patients seeking treatment at Hiwot Fana Comprehensive Specialized Hospital. Objective To assess PIMs use and associated factors among older patients receiving follow-up treatment at the chronic care clinic of Hiwot Fana Comprehensive Specialized Hospital in eastern Ethiopia. Methods A retrospective cross-sectional study using medical records of 419 older patients was conducted. older patients, aged 65 years or older, treated in the ambulatory care clinic were included. Simple random sampling technique was used. PIMs use was identified by using the 2023 American Geriatrics Society Beers Criteria (AGS Beers Criteria) and Screening Tool of Older People's Potentially Inappropriate Prescriptions Criteria and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) version 2 criteria. The multivariable logistic regression analysis was employed to identify factors associated with PIMs use. The strength of statistical association was measured by adjusted odds ratio (aOR) and 95% CI. P values < 0.05 were considered statistically significant. Results A total of 419 patients' medical records were reviewed. Of these, 411 patients' medical records fulfilled the inclusion criteria and were considered for final analysis. About 56.9% (n= 234) of the study population was women. The prevalence of PIMs use was 28.5% and 18.5%, according to 2023 AGS Beers Criteria and STOPP/START version 2 criteria, respectively. In accordance with 2023 AGS Beers Criteria, male sex (aOR = 1.78; 95% CI, 1.10-2.87), diabetes mellitus (aOR = 0.35; 95% CI, 0.19-0.62), and chronic kidney disease (aOR = 6.68; 95% CI, 2.55-9.32) were found to be the determining factors for PIMs use. According to STOPP/START version 2 criteria, deep vein thrombosis, diabetes mellitus, hypertension, and advanced age were the primary factors influencing PIMs use. Conclusions Compared with other study findings from across the world, the prevalence of PIMs use was low. Based on 2023 AGS Beers Criteria, male sex, diabetes mellitus, and chronic kidney disease were found to be the determinant factors for PIMs use. Deep vein thrombosis, diabetes mellitus, hypertension, and advanced age were significant factor of PIMs use according STOPP/START version 2 criteria.
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Affiliation(s)
- Shambel Nigussie
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Fekade Demeke
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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13
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Hareem A, Lee J, Stupans I, Park JS, Wang K. Benefits and barriers associated with e-prescribing in community pharmacy - A systematic review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100375. [PMID: 38145236 PMCID: PMC10746557 DOI: 10.1016/j.rcsop.2023.100375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Background The utilization of electronic prescribing is growing, prompted by lockdown measures during the COVID-19 pandemic. However, despite this increasing adoption, there is a notable dearth of consolidated evidence regarding the challenges and opportunities associated with the integration of electronic prescribing systems within the daily clinical practices of community pharmacists. Objective This paper aims to systematically review the community pharmacists' perspectives on barriers and facilitators to electronic prescribing, addressing the significant need for understanding how electronic prescribing impacts the workflow and decision-making processes of pharmacists, ultimately influencing the quality of patient care. Methods PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched from January 1, 2000, to October 25, 2022, using search terms related to electronic prescribing, computerised physician order entry, community/retail pharmacies, and pharmacists. Results A total of 28 studies were included in the systematic review. In these studies, community pharmacists perceived that design, interoperability, attitude towards e-prescribing technology, information quality, workflow, productivity, and accessible resources facilitated e-prescribing. In addition, the included studies emphasized the importance of technological support for the successful implementation of electronic prescribing systems. The system's design characteristics significantly improve e-prescribing technology's favourable effects. According to our review, it has been proposed that a poorly designed e-prescribing system can have a negative impact on the quality of care, implementation, and user satisfaction. In contrast, a well-designed system can significantly contribute to improvements. Conclusions The review highlighted that e-prescribing has both barriers and facilitators, with the quality of the system and its implementation influencing these factors. Technical issues and user acceptance (patient/prescribers/pharmacists) can act as barriers or enablers, highlighting the need for comprehensive consideration and monitoring of e-prescribing to identify and address potential issues.
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14
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D'Aiuto C, Lunghi C, Guénette L, Berbiche D, Bertrand K, Vasiliadis HM. Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada. BMC Health Serv Res 2023; 23:1295. [PMID: 38001466 PMCID: PMC10668473 DOI: 10.1186/s12913-023-10303-2] [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: 04/21/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Older adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system. METHODS The sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013-2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids. RESULTS Opioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use. CONCLUSIONS Potentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.
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Affiliation(s)
- Carina D'Aiuto
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke (Longueuil campus), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
| | - Carlotta Lunghi
- Department of Health Sciences, Université du Québec à Rimouski (Lévis campus), 1595 Boulevard Alphonse-Desjardins, Lévis, QC, G6V 0A6, Canada
- Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Center, 1050 Chemin Sainte-Foy, Québec, QC, G1S 4L8, Canada
- Department of Medical and Surgical Sciences, University of Bologna, Via Zamboni, 33, 40126, Bologna, BO, Italy
| | - Line Guénette
- Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Center, 1050 Chemin Sainte-Foy, Québec, QC, G1S 4L8, Canada
- Faculty of Pharmacy, Laval University, 1050 Av. de La Médecine, Québec City, QC, G1V 0A6, Canada
| | - Djamal Berbiche
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke (Longueuil campus), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
| | - Karine Bertrand
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke (Longueuil campus), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
| | - Helen-Maria Vasiliadis
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke (Longueuil campus), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada.
- Charles-Le Moyne Research Center (CR-CLM), 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada.
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15
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Laprise C. It's time to take a sustainable approach to health care in the face of the challenges of the 21st century. One Health 2023; 16:100510. [PMID: 36844975 PMCID: PMC9939387 DOI: 10.1016/j.onehlt.2023.100510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Health challenges in the 21st century have become increasingly complex and global. The recent COVID-19 pandemic has only exacerbated the many problems faced by health care systems around the world and sadly, exposed various flaws. With ageing populations, particularly in Canada, as well as unavoidable factors such as globalization and accelerating climate change, it is becoming imperative to implement a new health care approach based on intersectorality and interdisciplinarity. Furthermore, links must be forged between all the stakeholders, i.e. the researchers, the health system and its specialists, the communities and the individuals themselves. It is in this perspective, where everyone concerned must be equally involved in attaining a better quality of life, that the concepts of One Health and sustainable health must be deployed.
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Affiliation(s)
- Catherine Laprise
- Centre Intersectoriel en Santé Durable, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada,Département des Sciences Fondamentales, Université du Québec à Chicoutimi, Saguenay, QC G7H 2B1, Canada,Centre Intégré Universitaire en Santé et Services Sociaux du Saguenay–Lac-Saint-Jean, Saguenay, QC G7H 7K9, Canada,Corresponding author at : Département des Sciences Fondamentales, Université du Québec à Chicoutimi, Saguenay, Québec G7H 2B1, Canada
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16
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Mangin D, Lamarche L, Freeman K, Ali A, Clark R, Shah N, Awan A, Langevin J, Parascandalo J, Dore Brown N, Jurcic-Vrataric J, Colwill K, Dragos S, Borhan S, Risdon C, Siu H, Farrell B, Trimble J. Linking Patients' Goals and Priorities to Recommendations for Medication Changes in a Polypharmacy-Focused Structured Clinical Pathway. J Patient Exp 2023; 10:23743735231174762. [PMID: 37213440 PMCID: PMC10196540 DOI: 10.1177/23743735231174762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Polypharmacy is associated with poorer health outcomes in older adults. It is challenging to minimize the harmful effects of medications while maximizing benefits of single-disease-focused recommendations. Integrating patient input can balance these factors. The objectives are to describe the goals, priorities, and preferences of participants asked about these in a structured process to polypharmacy, and to describe the extent that decision-making within the process mapped onto these, signaling a patient-centered approach. This is a single-group quasi-experimental study, nested within a feasibility randomized controlled trial. Patient goals and priorities were mapped to medication recommendations made during the intervention. Overall, there were 33 participants who reported 55 functional goals and 66 symptom priorities, and 16 participants reported unwanted medications. Overall, 154 recommendations for medication alterations occurred. Of those, 68 (44%) recommendations mapped to the individual's goals and priorities, whereas the rest were based on clinical judgment where no priorities were expressed. Our results signal this process supports a patient-centered approach: allowing conversations around goals and priorities in a structured process to polypharmacy should be integrated into subsequent medication decisions.
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Affiliation(s)
- Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Larkin Lamarche
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karla Freeman
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Abbas Ali
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Clark
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nikki Shah
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amen Awan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Langevin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jenna Parascandalo
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Naomi Dore Brown
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kiska Colwill
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Dragos
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sayem Borhan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Henry Siu
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Farrell
- Department of Family Medicine, Bruyère
Research Institute, Ottawa, Ontario, Canada
| | - Johanna Trimble
- Patient Voices Network, BC Patient Safety and Quality
Council, Vancouver, British Columbia, Canada
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17
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Daunt R, Curtin D, O'Mahony D. Polypharmacy stewardship: a novel approach to tackle a major public health crisis. THE LANCET. HEALTHY LONGEVITY 2023; 4:e228-e235. [PMID: 37030320 DOI: 10.1016/s2666-7568(23)00036-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/10/2023] Open
Abstract
With growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Some studies have examined the effect of medication stewardship interventions in older patient cohorts, but focused on a narrow spectrum of potentially adverse medication practices, with mixed results. In response to the WHO challenge, we propose the novel concept of broad-spectrum polypharmacy stewardship, a coordinated intervention designed to improve the management of multimorbidities, taking into account potentially inappropriate medications, potential prescribing omissions, drug-drug and drug-disease interactions, and prescribing cascades, aligning treatment regimens with the condition, prognosis, and preferences of the individual patient. Although the safety and efficacy of polypharmacy stewardship need to be tested with well designed clinical trials, we propose that this approach could minimise medication-related harm in older people with multimorbidities exposed to polypharmacy.
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Affiliation(s)
- Ruth Daunt
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland
| | - Denis Curtin
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland
| | - Denis O'Mahony
- Department of Medicine, School of Medicine, University College Cork, and Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
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Gupta S, McColl MA, Smith K, McColl A. Prescribing patterns for treating common complications of spinal cord injury. J Spinal Cord Med 2023; 46:237-245. [PMID: 33955832 PMCID: PMC9987774 DOI: 10.1080/10790268.2021.1920786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The purpose of this study was to find the most and least commonly prescribed medications for treating secondary health complications associated with spinal cord injury (SCI); and determine overall polypharmacy rates and risk factors associated with it. DESIGN Observational design, cross-sectional analysis. SETTING Community; Canada. PARTICIPANTS Individuals with spinal cord injury (n = 108). RESULTS A total of 515 prescriptions were issued to the sample comprising 213 different medications to treat 10 SCI-related complications. Forty-five (45%) participants were prescribed >5 medications concurrently. No associations were found between the number of drugs taken and age, sex, level of injury, completeness of injury, time since injury, or cause of injury. The most commonly treated complications included pain (56.5%), muscle spasms (54%) and urinary tract infections (43%). Anti-convulsants (pregabalin, gabapentin), anti-spasmodics (baclofen, diazepam) and nitrofurantoins (Macrobid) were the most commonly prescribed medications to treat each of the three conditions, respectively. Thirty five percent of the total sample received a combination of two or more analgesics including fourth-line agents in the opiate class (hydromorphone, hydrocodone and morphine). Similarly, some participants were prescribed general muscle relaxants and cephalosporins for treatment of muscle spasms and urinary tract infections, respectively, that are generally not recommended in SCI patients. We compare these prescribing patterns with the available clinical practice guidelines and highlight areas where the prescriptions fall outside the recommended clinical practice while considering the complexity of medication management in SCI. CONCLUSION Medication management in SCI is complex. Tools are required that enable prescribers to choose evidence-based medical regimens and deprescribe potentially inappropriate medications for their patients with SCI.
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Affiliation(s)
- Shikha Gupta
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Mary Ann McColl
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Karen Smith
- Department of Physical Medicine and Rehabilitation, School of Medicine, Queen's University, Kingston, Canada
| | - Alexander McColl
- Rural Clinical School in Family Medicine, University of New South Wales, Sydney, Australia
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Ferro-Uriguen A, Beobide-Telleria I, Gil-Goikouria J, Peña-Labour PT, Díaz-Vila A, Herasme-Grullón AT, Echevarría-Orella E. Effectiveness of a Person-Centered Prescription Model in Hospitalized Older People at the End of Life According to Their Disease Trajectories and Frailty Index. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3542. [PMID: 36834233 PMCID: PMC9967609 DOI: 10.3390/ijerph20043542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
This study aimed to comparatively analyze the effect of the person-centered prescription (PCP) model on pharmacotherapeutic indicators and the costs of pharmacological treatment between a dementia-like trajectory and an end-stage organ failure trajectory, and two states of frailty (cut-off point 0.5). A randomized controlled trial was conducted with patients aged ≥65 years admitted to a subacute hospital and identified by the Necessity of Palliative Care test to require palliative care. Data were collected from February 2018 to February 2020. Variables assessed included sociodemographic, clinical, degree-of-frailty, and several pharmacotherapeutic indicators and the 28-day medication cost. Fifty-five patients with dementia-like trajectory and 26 with organ failure trajectory were recruited observing significant differences at hospital admission in the mean number of medications (7.6 vs. 9.7; p < 0.004), the proportion of people on more than 10 medications (20.0% vs. 53.8%; p < 0.002), the number of drug-drug interactions (2.7 vs. 5.1; p < 0.006), and the Medication Regimen Complexity Index (MRCI) (25.7 vs. 33.4; p < 0.006), respectively. Also, regarding dementia-like patients, after application of the PCP model, these patients improved significantly in the intervention group compared to the control group in the mean number of chronic medications, STOPP Frail Criteria, MRCI and the 28-day cost of regular medications (p < 0.05) between admission and discharge. As for the PCP effect on the control and the intervention group at the end-stage organ failure, we did not observe statistically significant differences. On the other hand, when the effect of the PCP model on different degrees of frailty was evaluated, no unequal behavior was observed.
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Affiliation(s)
| | - Idoia Beobide-Telleria
- Department of Pharmacy, Ricardo Bermingham Hospital—Matia Foundation, 20018 Donostia, Spain
| | - Javier Gil-Goikouria
- Department of Physiology, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain
- Network Centre for Biomedical Research in Mental Health to the Institute of Health Carlos III (CIBERSAM ISCIII), 28029 Madrid, Spain
| | | | - Andrea Díaz-Vila
- Department of Geriatrics, Ricardo Bermingham Hospital—Matia Foundation, 20018 Donostia, Spain
| | | | - Enrique Echevarría-Orella
- Department of Physiology, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain
- Network Centre for Biomedical Research in Mental Health to the Institute of Health Carlos III (CIBERSAM ISCIII), 28029 Madrid, Spain
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20
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The MGPIDP-L project: Potentially inappropriate drug prescribing and its associated factors. Arch Gerontol Geriatr 2023; 109:104947. [PMID: 36746016 DOI: 10.1016/j.archger.2023.104947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/22/2022] [Accepted: 01/27/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of this study was to identify the prevalence of potentially inappropriate drug prescribing1 (PIDP) using a combination of explicit and implicit criteria in a sample of Lebanese older adults taking 5 or more chronic medications per day in ambulatory care settings and to identify which factors were associated with PIDP. The explicit criteria included five different lists: Beers, Laroche, European Union (EU(7)-PIM list), STOPP/ START, STOPP Frail, and Alert and Mastering of Iatrogenesis issued by the French High Authority of Health. We also performed a sensitivity analysis to compare the potentially inappropriate medications according to each criterion. METHODS Data were collected from each patient via a face-to-face interview. Logistic regressions were conducted to evaluate both objectives. RESULTS Many factors were positively associated with PIDP. The risk of PIDP was positively associated with age (OR =4.692, 95% CI [1.889-11.655]). Treatment for insomnia doubled the odds of PIDP (P<0.05). Participants who picked their medications from the pharmacy and had excess stock of drugs were at higher risk of having PIDP by 2.042 (95% CI [1.199-3.478]) and 2.965(95% CI [1.133-7.762]) respectively. However, patients with a perception of being heavily medicated and patients with a missed dose in the last two weeks had lower odds of PIDP. CONCLUSION Our study showed a high prevalence of PIDP in Lebanon, which is associated with various correlates. Selecting the appropriate tools to assess PIDP and providing patient education regarding the risks associated with potentially inappropriate medications are issues to be addressed among older adults.
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Alfahmi AA, Curtain CM, Salahudeen MS. Assessment of Knowledge, Attitude and Practices of the Hospital and Community Pharmacists in Saudi Arabia (Jeddah) towards Inappropriate Medication Use in Older Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1635. [PMID: 36674385 PMCID: PMC9863709 DOI: 10.3390/ijerph20021635] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 06/17/2023]
Abstract
In Saudi Arabia, the older adult population is growing and is projected to increase three-fold by 2030. Potentially inappropriate medications (PIMs) are harmful to older adults' and have a direct impact on clinical, health and economic outcomes. Pharmacists have a vital role in medication tailoring for older adults as multidisciplinary team members. However, there is also a paucity of research regarding pharmacists' participation in detecting and avoiding PIMs use among older adults in Saudi Arabia. A cross-sectional, self-administered survey was conducted to assess the knowledge, practices, and attitude of pharmacists from seven hospitals and ten community pharmacies in Jeddah, Saudi Arabia. The survey comprised three sections; (i) identifying participants' general characteristics, (ii) assessing their knowledge of PIMs use in older adults and (iii) examining the pharmacist's attitude towards the procedures followed in dispensing for older adults. Inferential and descriptive statistics were used to analyse the survey data. A total of 157 community and hospital pharmacists participated in this study. Most of them dispensed medication weekly to older adults (85.4%), and 43.3% had relevant work experience of six to ten years. Though 44.6% of the participants were aware of PIMs that older adults should avoid, only 10.8% claimed adequate knowledge about PIMs. From the given three clinical case scenarios, a minority of pharmacists (21.7%) chose the correct answers, with a mean score of 2.38 ± 2.91 (95% CI 2.35-3.15). Participants who claimed to have knowledge of PIMs had a significantly higher mean score than those who did not, 4.59 ± 2.81 25 (95% CI 2.35-2.61). A minority of the pharmacists (14.7%) used screening tools such as STOPP, Beers criteria, or Medication Appropriateness Index (MAI) to detect PIMs in older adults. No statistically significant differences were detected when comparing the levels of knowledge of pharmacists with 1 to 5 years of practice to pharmacists with 6 to 15 and more years of experience (p = 0.431). Pharmacists' knowledge, attitude and practices toward PIMs use in older adults in Saudi Arabia should be improved. The application of PIMs detection tools such as STOPP/START or Beers criteria currently has no place in day-to-day pharmacists' roles in Saudi Arabia. Therefore, concerned stakeholders should develop educational programs to improve pharmacists' knowledge of PIMs and promote the effective use of PIM screening tools such as Beers and STOPP criteria in their practice.
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Awad A, Al-Otaibi H, Al-Tamimi S. Prescribing Practices in Geriatric Patients with Cardiovascular Diseases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:766. [PMID: 36613087 PMCID: PMC9819083 DOI: 10.3390/ijerph20010766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Inappropriate prescribing (IP) increases the risk of adverse medication reactions and hospitalizations in elderly patients. Therefore, it is crucial to evaluate prescribing patterns among this population. This study was designed to assess the prevalence of potentially inappropriate medication (PIMs) use and potential prescribing omissions (PPOs) among geriatrics with cardiovascular diseases (CVDs). In addition, it determined the predictors for IP in this population. A multi-center study was performed retrospectively on 605 patients' medical records collected randomly from seven governmental hospitals in Kuwait. Three of these hospitals have specialized cardiac centers (tertiary care). Inclusion criteria were age ≥ 65 years, diagnosed with at least one CVD, and attended the outpatient clinic during the last 6 months before data collection. A total of 383 patients (63.3%; 95% CI: 59.3-67.1%) were found using at least one PIM or having PPO or both, based on STOPP/START criteria. Three hundred and ninety-one patients (64.6%; 95% CI: 60.7-68.4%) were prescribed PIMs categorized as C and/or D medicines according to the Euro-FORTA list. Over one-quarter (28.8%; 95% CI: 25.2-32.6%) of the patients had drug-drug interactions class D that require therapy modification and/or X that should be avoided. Patients taking ≥ five medications had significantly higher PIMs based on STOPP and FORTA criteria, drug-drug interactions (p < 0.001), and significantly higher PPOs based on START criteria (p = 0.041). Patients with three or more chronic diseases had significantly higher PIMs based on STOPP and FORTA criteria and PPOs based on START criteria (p-values: 0.028, 0.035, and 0.005, respectively). Significantly higher PIMs based on STOPP criteria and PPOs based on START criteria were found in general hospitals compared to specialized cardiac centers (p= 0.002, p= 0.01, respectively). These findings highlight the need to develop and implement multifaceted interventions to prevent or minimize inappropriate prescribing among the geriatric population with CVDs in Kuwait.
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Affiliation(s)
- Abdelmoneim Awad
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City 13110, Kuwait
| | - Haya Al-Otaibi
- Al-Adan Hospital, Ministry of Health, Al-Ahmadi 47005, Kuwait
| | - Sara Al-Tamimi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City 13110, Kuwait
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Ouellet N, Bergeron AS, Gagnon E, Cossette B, Labrecque CA, Sirois C. Prescribing and deprescribing in very old age: perceptions of very old adults, caregivers and health professionals. Age Ageing 2022; 51:6827077. [PMID: 36413585 DOI: 10.1093/ageing/afac244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND although they are major consumers of medications, there is little evidence-based data to guide prescribing and deprescribing of medications for very old adults (80+ years). OBJECTIVES to discover the perceptions of very old adults, caregivers and health professionals in order to further examine the clinical and ethical issues raised by prescribing and deprescribing in very old age. METHODS individual interviews were conducted with very old adults (n = 10) and caregivers (n = 6), whereas group interviews were conducted with health professionals (n = 11). The themes covered included perceptions of medication use, polypharmacy, deprescribing and patient-health professional relationships. Thematic analysis was used to identify areas of convergence and divergence. RESULTS very old adults are satisfied with the medications they are taking, do not see the need to reduce their medication use and consider their doctor as the expert who should make the decisions regarding treatment. The perceptions of caregivers are similar to those of older adults, whereas health professionals believe that very old adults take a lot of inappropriate medications and list multiple barriers to deprescribing. All participants describe a normalisation of medication use with ageing. CONCLUSION there is a dichotomy between the perception of the very old adults/caregivers and that of health professionals regarding the safety of medication in very old age. A cultural change regarding medication use seems essential to optimise therapy and support deprescribing in clinical practice since the potential issues raised by researchers do not resonate with the main stakeholders.
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Affiliation(s)
- Nicole Ouellet
- Département des Sciences Infirmières, Université du Québec à Rimouski, Rimouski, Québec, Canada
| | - Anne-Sophie Bergeron
- Département des Sciences Infirmières, Université du Québec à Rimouski, Rimouski, Québec, Canada
| | - Eric Gagnon
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.,VITAM - Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et de Services Sociaux, Québec, Canada
| | - Benoit Cossette
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada.,Research Center on Aging, Integrated University Health and Social Services Center of Estrie-Sherbrooke University Hospital Center, Sherbrooke, Québec, Canada
| | - Cory A Labrecque
- Faculté de Théologie et de Sciences Religieuses, Université Laval, Québec, Canada
| | - Caroline Sirois
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.,VITAM - Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et de Services Sociaux, Québec, Canada.,Faculté de Pharmacie, Université Laval, Laval, Québec, Canada
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Rantsi M, Pitkälä KH, Kautiainen H, Hyttinen V, Kankaanpää E. Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication. Age Ageing 2022; 51:6590511. [PMID: 35604803 PMCID: PMC9126199 DOI: 10.1093/ageing/afac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). Methods The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period. Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. Results The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY. Conclusion The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.
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Affiliation(s)
- Mervi Rantsi
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Kaisu H Pitkälä
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Hannu Kautiainen
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Eila Kankaanpää
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
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Evaluation approaches, tools and aspects of implementation used in pharmacist interventions in residential aged care facilities: A scoping review. Res Social Adm Pharm 2022; 18:3714-3723. [DOI: 10.1016/j.sapharm.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/15/2022] [Accepted: 05/07/2022] [Indexed: 11/21/2022]
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Squires JE, Cho-Young D, Aloisio LD, Bell R, Bornstein S, Brien SE, Decary S, Varin MD, Dobrow M, Estabrooks CA, Graham ID, Greenough M, Grinspun D, Hillmer M, Horsley T, Hu J, Katz A, Krause C, Lavis J, Levinson W, Levy A, Mancuso M, Morgan S, Nadalin-Penno L, Neuner A, Rader T, Santos WJ, Teare G, Tepper J, Vandyk A, Wilson M, Grimshaw JM. Inappropriate use of clinical practices in Canada: a systematic review. CMAJ 2022; 194:E279-E296. [PMID: 35228321 PMCID: PMC9053971 DOI: 10.1503/cmaj.211416] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. Methods: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. Results: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9). Interpretation: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.
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Affiliation(s)
- Janet E Squires
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta.
| | - Danielle Cho-Young
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Laura D Aloisio
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Robert Bell
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Stephen Bornstein
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Susan E Brien
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Simon Decary
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Melissa Demery Varin
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Mark Dobrow
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Carole A Estabrooks
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Ian D Graham
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Megan Greenough
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Doris Grinspun
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Hillmer
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tanya Horsley
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jiale Hu
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Alan Katz
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Christina Krause
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - John Lavis
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wendy Levinson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Adrian Levy
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michelina Mancuso
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Steve Morgan
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Letitia Nadalin-Penno
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Andrew Neuner
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tamara Rader
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wilmer J Santos
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Gary Teare
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Joshua Tepper
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Amanda Vandyk
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Wilson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
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Pickering AN, Walter EL, Dawdani A, Decker A, Hamm ME, Gellad WF, Radomski TR. Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study. BMC Geriatr 2022; 22:152. [PMID: 35209856 PMCID: PMC8867785 DOI: 10.1186/s12877-022-02829-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios. METHODS As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing. RESULTS We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations. CONCLUSIONS When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.
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Affiliation(s)
- Aimee N Pickering
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Center for Research on Healthcare, 3609 Forbes Avenue, 2nd Floor, Pittsburgh, PA, 15213, USA.
| | - Eric L Walter
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alicia Dawdani
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Decker
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Megan E Hamm
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Aida K, Azuma K, Mishima S, Ishii Y, Suzuki S, Oda J, Honma H. Potentially inappropriate medications at admission among elderly patients transported to a tertiary emergency medical institution in Japan. Acute Med Surg 2022; 9:e748. [PMID: 35386514 PMCID: PMC8976156 DOI: 10.1002/ams2.748] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/05/2022] [Accepted: 03/17/2022] [Indexed: 11/13/2022] Open
Abstract
Aim Potentially inappropriate medications (PIMs) have been reported to be associated with lower adherence, higher rates of adverse events, and higher health‐care costs in elderly patients with high comorbidity. However, inappropriate prescribing has not been adequately reported in studies of patients transported to tertiary care hospitals. In this study, we investigated PIMs at the time of admission, on the basis of the prescription status of elderly patients admitted to a tertiary emergency room (ER). Methods We included 316 patients (168 men and 148 women, aged 75–97 years) who were admitted to our ER from September 2018 to August 2019, whose prescriptions were available on admission. Drugs that met the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria version 2 were defined as PIMs. The primary outcome was the proportion of older adults taking at least one PIM at admission. Results The proportion of patients taking PIMs at admission was 57% (n = 179). The most common PIMs were benzodiazepines, proton pump inhibitors, and nonsteroidal anti‐inflammatory drugs. The total number of medications prescribed at admission, prescriptions from multiple institutions, and prescriptions from clinics were the risk factors for PIMs at admission (P < 0.01, P < 0.001, and P < 0.001, respectively). Conclusion We must be careful to avoid inappropriate prescribing for patients transported to tertiary care hospitals who have numerous prescriptions at the time of admission, patients who receive prescriptions from multiple medical institutions, and patients who receive prescriptions from clinics.
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Affiliation(s)
- Kenta Aida
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kazunari Azuma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shiro Mishima
- Department of Medical Safety Management Tokyo Medical University Tokyo Japan
| | - Yuri Ishii
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shoji Suzuki
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Hiroshi Honma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
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Swanner AA, Hawley CE, Li K, Triantafylidis LK, Li J, Paik JM. Medication Optimization for New Initiators of Empagliflozin for Diabetic Kidney Disease. Clin Diabetes 2022; 40:158-167. [PMID: 35669297 PMCID: PMC9160537 DOI: 10.2337/cd21-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended agents for the treatment of diabetic kidney disease (DKD). Additionally, SGLT2 inhibitors lower blood glucose, decrease blood pressure, and can be useful for volume management. For these reasons, we hypothesized that initiating SGLT2 inhibitor therapy may be associated with deprescribing of other medications in patients with DKD. We compared medication lists at SGLT2 inhibitor initiation and 6 months post-initiation in 21 patients with DKD who were followed in our interprofessional outpatient nephrology clinic to evaluate deprescribing patterns in diabetes, hypertension, and diuretic medications. Six months of SGLT2 inhibitor therapy in patients with DKD was associated with deprescribing of high-risk diabetes agents, antihypertensives, and loop diuretics with minimal changes in A1C and fewer adverse events.
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Affiliation(s)
| | - Chelsea E. Hawley
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston
| | - Kay Li
- Pharmacy Department, VA Boston Healthcare System, Boston
| | | | - Jiahua Li
- Renal Section, VA Boston Healthcare System, Boston
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Julie M. Paik
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston
- Renal Section, VA Boston Healthcare System, Boston
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Corresponding author: Julie M. Paik,
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Aida K, Azuma K, Mishima S, Ishii Y, Suzuki S, Oda J. Potentially inappropriate medications at discharge among elderly patients at a single tertiary emergency medical institution in Japan: a retrospective cross-sectional observational study. Acute Med Surg 2021; 8:e711. [PMID: 34876989 PMCID: PMC8628299 DOI: 10.1002/ams2.711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 11/15/2022] Open
Abstract
Aim Potentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors. Methods In total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge. Results The proportions of patients taking PIMs at admission and discharge were 55% (n = 175) and 28% (n = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge. Conclusions Admission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs.
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Affiliation(s)
- Kenta Aida
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kazunari Azuma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shiro Mishima
- Department of Medical Safety Management Tokyo Medical University Tokyo Japan
| | - Yuri Ishii
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shoji Suzuki
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
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Staples JA, Liu G, Brubacher JR, Karimuddin A, Sutherland JM. Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis. J Gen Intern Med 2021; 36:3431-3440. [PMID: 33948803 PMCID: PMC8606373 DOI: 10.1007/s11606-021-06803-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge. OBJECTIVE To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions. DESIGN Interrupted time series analysis of population-based hospitalization data. PARTICIPANTS Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017. MAIN MEASURES The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy. KEY RESULTS A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval. CONCLUSION The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere. TRIAL REGISTRATION ClinicalTrials.gov ID, NCT03256734.
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Affiliation(s)
- John A. Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R. Brubacher
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Ahmer Karimuddin
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jason M. Sutherland
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Alshammari H, Al-Saeed E, Ahmed Z, Aslanpour Z. Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review. Drug Healthc Patient Saf 2021; 13:183-210. [PMID: 34764701 PMCID: PMC8572741 DOI: 10.2147/dhps.s303101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 07/16/2021] [Indexed: 12/29/2022] Open
Abstract
Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.
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Affiliation(s)
- Hesah Alshammari
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Correspondence: Hesah Alshammari Email
| | - Eman Al-Saeed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zamzam Ahmed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Thomson WM, Smith MB, Ferguson CA, Moses G. The Challenge of Medication-Induced Dry Mouth in Residential Aged Care. PHARMACY 2021; 9:162. [PMID: 34698291 PMCID: PMC8544708 DOI: 10.3390/pharmacy9040162] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/27/2022] Open
Abstract
With a reported prevalence between 20% and 30%, dry mouth is more common among older people than any other age group. The major risk factor for dry mouth is polypharmacy. Older people take more medications than any other age group, not only for symptomatic relief of various age-associated chronic diseases, but also to reduce the likelihood of the complications that may arise from those conditions. Most aged care residents take even more medications than older people who are living in their own homes. The greater the number of medications taken, the greater the associated anticholinergic burden, and the more likely it is that the individual will suffer from dry mouth. The condition not only affects the dentition and ability to wear dentures, but also the sufferers' quality of life. Treating dry mouth is a considerable challenge for clinicians. As medication use is by far the most important risk factor, there is a need for pharmacists, doctors and dentists to work together to prevent this from occurring. Medication review and deprescribing is a key strategy, but there have not yet been any randomised control trials of its efficacy in reducing the occurrence of dry mouth.
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Affiliation(s)
- William Murray Thomson
- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin 9054, New Zealand
| | - Moira B. Smith
- Department of Public Health, Wellington School of Medicine, Faculty of Medicine, University of Otago, Wellington 6021, New Zealand; (M.B.S.); (C.A.F.)
| | - Catherine Anna Ferguson
- Department of Public Health, Wellington School of Medicine, Faculty of Medicine, University of Otago, Wellington 6021, New Zealand; (M.B.S.); (C.A.F.)
| | - Geraldine Moses
- School of Pharmacy, University of Queensland, Brisbane 4102, Australia;
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Roux B, Bezin J, Morival C, Noize P, Laroche ML. Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study. Expert Rev Pharmacoecon Outcomes Res 2021; 22:627-636. [PMID: 34525899 DOI: 10.1080/14737167.2021.1981863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France. METHODS A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population. RESULTS The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million). CONCLUSIONS PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
| | - Julien Bezin
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Camille Morival
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Pernelle Noize
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Laboratoire Vie-Santé (Vieillissement Fragilité Prévention, e-Santé), IFR GEIST, Université de Limoges, Limoges, France
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Magin P, Quain D, Tapley A, van Driel M, Davey A, Holliday E, Ball J, Kaniah A, Turner R, Spike N, FitzGerald K, Hilmer S. Deprescribing in older patients by early-career general practitioners: Prevalence and associations. Int J Clin Pract 2021; 75:e14325. [PMID: 33960089 DOI: 10.1111/ijcp.14325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 12/09/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
RATIONALE AND AIMS Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs. METHODS A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines. RESULTS One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration). CONCLUSION These findings will have important implications for the education of GPs in deprescribing as a clinical skill.
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Affiliation(s)
- Parker Magin
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Debbie Quain
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Amanda Tapley
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Mieke van Driel
- Discipline of General Practice and Primary Care Clinical Unit, Faculty of Medicine, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Andrew Davey
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Jean Ball
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ashwin Kaniah
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Rachel Turner
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Medical Education, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT) Churchill, Churchill, Vic, Australia
- Department of General Practice and Primary Health Care Carlton, University of Melbourne, Melbourne, Vic, Australia
| | | | - Sarah Hilmer
- University of Sydney and Royal North Shore Hospital, Kolling Institute, St Leonards, NSW, Australia
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A Systematic Review of Potentially Inappropriate Medications Use and Related Costs Among the Elderly. Value Health Reg Issues 2021; 25:172-179. [PMID: 34311335 DOI: 10.1016/j.vhri.2021.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/14/2021] [Accepted: 05/27/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Potentially inappropriate medications (PIMs) use is a common phenomenon among older adults. This paper aimed to perform a systematic literature review to assess PIMs use and related costs among elderly persons. METHODS This study was a systematic review. PubMed, Scopus, and the Institute for Scientific Information engines were used to search for all relevant studies published until 2020. Studies were excluded if they did not estimate the cost of PIMs for the elderly. In addition, non-English articles, editorials, letters, and review articles were excluded. All eligible articles were assessed for methodological quality. Finally, we extracted general characteristics from each eligible study. RESULTS This study showed that the prevalence of PIMs use among older adults was more than 30%. Drugs related to the central nervous system and cardiovascular disease, benzodiazepines, analgesics, and nonsteroidal anti-inflammatory drugs were most commonly used as PIMs. These studies concluded that PIMs could impose a high economic burden on the elderly and society. The mean cost for older adults with PIMs use was almost USD$2000 more than the mean cost for older adults without PIMs. Additionally, the total cost of PIMs use for all elderly persons in Canada in 2013 was estimated at USD$419 million. CONCLUSIONS Focusing on the most common PIMs, such as benzodiazepines and nonsteroidal anti-inflammatory drugs, helps implementing cost-effective strategies for reducing PIMs use and decreasing their clinical and economic effects.
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Davenport Huyer L, Desveaux L, Nakhla N, Maxwell C, Tadrous M. 'Fitting in the pharmacist' - a qualitative analysis of the perceived relationship between community pharmacists and older adults with complex care needs. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:428-434. [PMID: 34244751 DOI: 10.1093/ijpp/riab034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/28/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To explore the current perceived relationship between older adults with varying levels of frailty and healthcare needs and community pharmacists. METHODS This qualitative study conducted a thematic analysis of focus groups with older adults and older adult caregivers and community pharmacist participants. Participants were recruited following a maximum variation sampling technique. Verbatim transcripts were inductively coded using NVivo to develop key findings. KEY FINDINGS Four major themes emerged: (i) Pharmacy Landscape, (ii) Prescription and Non-Prescription Drug Safety, (iii) Patient-Pharmacist Relationship and (iv) Recommendations for Pharmacy Practice. Themes demonstrate three key findings: (1) older adults approach drug information with a key focus on safety and cost of both prescription and non-prescription drugs, (2) there is a demonstrated opportunity, recognized by older adults and practitioners, for community pharmacists to expand their role in the care of older adults, (3) community pharmacists are able, interested and/or have already incorporated frailty assessments into their practice to better support their care of the older adult population with varying levels of frailty. CONCLUSIONS The results demonstrate a reason for the community pharmacist role to shift. The unique knowledge and skills of community pharmacists, coupled with their accessibility and strong patient-clinician relationship, have the potential to better support older adults with varying levels of frailty.
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Affiliation(s)
- Larkin Davenport Huyer
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Laura Desveaux
- Institute for Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Nardine Nakhla
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada
| | - Colleen Maxwell
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada
| | - Mina Tadrous
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Migliazza K, Bähler C, Liedtke D, Signorell A, Boes S, Blozik E. Potentially inappropriate medications and medication combinations before, during and after hospitalizations: an analysis of pathways and determinants in the Swiss healthcare setting. BMC Health Serv Res 2021; 21:522. [PMID: 34049550 PMCID: PMC8164287 DOI: 10.1186/s12913-021-06550-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background A hospitalization phase represents a challenge to medication safety especially for multimorbid patients as acute medical needs might interact with pre-existing medications or evoke adverse drug effects. This project aimed to examine the prevalence and risk factors of potentially inappropriate medications (PIMs) and medication combinations (PIMCs) in the context of hospitalizations. Methods Analyses are based on claims data of patients (≥65 years) with basic mandatory health insurance at the Helsana Group, and on data from the Hirslanden Swiss Hospital Group. We assessed PIMs and PIMCs of patients who were hospitalized in 2013 at three different time points (quarter prior, during, after hospitalization). PIMs were identified using the PRISCUS list, whereas PIMCs were derived from compendium.ch. Zero-inflated Poisson regression models were applied to determine risk factors of PIMs and PIMCs. Results Throughout the observation period, more than 80% of patients had at least one PIM, ranging from 49.7% in the pre-hospitalization, 53.6% in the hospitalization to 48.2% in the post-hospitalization period. PIMCs were found in 46.6% of patients prior to hospitalization, in 21.3% during hospitalization, and in 25.0% of patients after discharge. Additional medication prescriptions compared to the preceding period and increasing age were the main risk factors, whereas managed care was associated with a decrease in PIMs and PIMCs. Conclusion We conclude that a patient’s hospitalization offers the possibility to increase medication safety. Nevertheless, the prevalence of PIMs and PIMCs is relatively high in the study population. Therefore, our results indicate a need for interventions to increase medication safety in the Swiss healthcare setting.
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Affiliation(s)
- Kevin Migliazza
- Department of Health Sciences, Helsana Group, Zürich, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Group, Zürich, Switzerland
| | | | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zürich, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zürich, Switzerland. .,Institute of Primary Care, University of Zürich, Zürich, Switzerland.
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Aref HAT, Kolewaski L, Whitfield KY, Sadowski CA, Guirguis LM. Implementing the Med Wise Program in rural Alberta: A feasibility study to support seniors. Can Pharm J (Ott) 2021; 154:87-92. [PMID: 33868519 DOI: 10.1177/1715163521990401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Heba A T Aref
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton
| | | | | | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton
| | - Lisa M Guirguis
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton
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Lin W, Haq S, Sinha S, Fan-Lun C. Impact Analysis of a Pharmacist-Led Home-Medication Review Service Within an interprofessional Outreach Team. Sr Care Pharm 2021; 36:159-170. [PMID: 33662240 DOI: 10.4140/tcp.n.2021.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the demographic and clinical characteristics of frail and homebound communitydwelling older patients receiving a home medication review (HMR) conducted by a home-visiting pharmacist; the types of drug therapy problems (DTPs) that were identified; the types of clinical interventions being recommended and their implementation rate. DESIGN Retrospective, cross-sectional chart-review study using data from patient records. SETTING Homes of patients receiving a HMR by a community pharmacy-based consulting home-visiting pharmacist. PATIENTS 171 patients received a HMR between January 1, 2016, and May 31, 2018. INTERVENTION Patients received a comprehensive HMR by a home-visiting pharmacist working as a member of an interprofessional geriatrics team. MAIN OUTCOME MEASURES Charlson Comorbidity Index (CCI) score, comorbidities, use of potentially inappropriate medications, DTPs identified, number and type of clinical interventions being recommended and successfully implemented. RESULTS Patients had a mean age of 81 years (range: 54-100 years), majority were 65 years of age or older (95%), and female (59%). Fifty-three percent of patients had a CCI score of 1 to 2, and 93.6% were experiencing multi-morbidity and polypharmacy. Patients used an average of 13.0 medications, and 76.1% were found to be using at least 1 potentially inappropriate medication. In total, the home-visiting pharmacist identified 827 DTPs and made 1088 recommendations with a successful implementation rate of 74%. CONCLUSIONS Frail and homebound communitydwelling older adults referred for a HMR were observed to be using a high number of medications with a significant number of DTPs identified. Offering HMRs was an effective method for a community-based pharmacist to make acceptable recommendations to optimize medication therapy management for frail older patients.
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Affiliation(s)
- Wuqi Lin
- 1University of Toronto, Toronto, Ontario, Canada
| | | | - Samir Sinha
- 1University of Toronto, Toronto, Ontario, Canada
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Lee J, Muratov S, Tarride JE, Paterson JM, Thavorn K, Mbuagbaw L, Gomes T, Khuu W, Seow H, Thabane L, Holbrook A. Medication use and its impact on high-cost health care users among older adults: protocol for the population-based matched cohort HiCOSTT study. CMAJ Open 2021; 9:E44-E52. [PMID: 33436455 PMCID: PMC7843076 DOI: 10.9778/cmajo.20190196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Health interventions and policies for high-cost health care users (HCUs) who are older adults need to be informed by a better understanding of their multimorbidity and medication use. This study aims to determine the financial contribution of medications to HCU expenditures and explore whether potentially inappropriate prescribing is associated with incident HCU development. METHODS This is a protocol for a retrospective population-based matched cohort analysis of incident older adult HCUs (those with the highest 5% of costs and 66 years of age or older) in Ontario during fiscal year 2013. We will obtain person-level data for the index year and year before HCU status from health administrative databases and match each HCU to 3 non-HCUs based on age, sex and geographic location. Average annual medication costs (per patient) and the ratio of medication to total health care costs (at population level) will be examined over the HCU transition period and compared with non-HCUs. We will explore potential quality improvement areas for prescribing by analyzing chronic conditions and the use of medications with a strong evidence base for either clinical benefit or risk of harms outweighing benefits in older adults with these diagnoses. The relation between these medication classes and incident HCU status will be explored using logistic regression. INTERPRETATION Using a matched cohort design and focusing on incident rather than prevalent HCUs, this protocol will explore our hypotheses that medications and the quality of their prescribing may be important triggers of HCU status and facilitate the identification of potential preventive clinical interventions or policies. Dissemination of results will occur via publications in peer-reviewed journals, presentations at conferences and academic settings, and knowledge translation activities with relevant health system and patient stakeholder groups. STUDY REGISTRATION Clinicaltrials.gov, no. NCT02815930.
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Affiliation(s)
- Justin Lee
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.
| | - Sergei Muratov
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jean-Eric Tarride
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - J Michael Paterson
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Kednapa Thavorn
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Lawrence Mbuagbaw
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Tara Gomes
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Wayne Khuu
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Hsien Seow
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Lehana Thabane
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Anne Holbrook
- Division of Geriatric Medicine (Lee), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Lee, Muratov, Tarride, Mbuagbaw, Seow, Thabane, Holbrook), and Centre for Health Economics and Policy Analysis (CHEPA) (Tarride), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes, Khuu, Seow, Thavorn); Institute of Health Policy, Management and Evaluation (Paterson, Thavorn), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Thavorn), The Ottawa Hospital, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital, Toronto, Ont.; Department of Oncology (Seow), Faculty of Health Sciences, and Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
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Amorim WW, Passos LC, Gama RS, Souza RM, Graia LT, Macedo JC, Santos DB, Oliveira MG. Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil. SAO PAULO MED J 2021; 139:107-116. [PMID: 33825769 PMCID: PMC9632519 DOI: 10.1590/1516-3180.2020.0411.r1.18112020] [Citation(s) in RCA: 5] [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] [Received: 07/21/2020] [Accepted: 11/18/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population. OBJECTIVES To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors. DESIGN AND SETTING This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations. METHODS Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription. RESULTS In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications. CONCLUSIONS High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.
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Affiliation(s)
- Welma Wildes Amorim
- MD, PhD. Internal Medicine Professor, Medicine Course, Department of Natural Sciences, Vitória da Conquista Campus, Universidade Estadual do Sudoeste da Bahia (UESB), Vitória da Conquista (BA), Brazil.
| | - Luiz Carlos Passos
- MD, PhD. Internal Medicine Professor, Postgraduate Program on Medicine and Health, Department of Internal Medicine, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.
| | - Romana Santos Gama
- BPharm. Master's Student, Postgraduate Program on Medicine and Health, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.
| | - Renato Morais Souza
- BPharm. Research Assistant, Multidisciplinary Health Institute, Anísio Teixeira Campus, Universidade Federal da Bahia (UFBA), Vitória da Conquista (BA), Brazil.
| | - Lucas Teixeira Graia
- BPharm. Research Assistant, Multidisciplinary Health Institute, Anísio Teixeira Campus, Universidade Federal da Bahia (UFBA), Vitória da Conquista (BA), Brazil.
| | - Jéssica Caline Macedo
- BPharm. Master's Student, Master's Program on Collective Health, Multidisciplinary Health Institute, Anísio Teixeira Campus, Universidade Federal da Bahia (UFBA), Vitória da Conquista (BA), Brazil.
| | - Djanilson Barbosa Santos
- PhD. Epidemiology Professor, Department of Collective Health, Universidade Federal do Recôncavo da Bahia (UFRB), Santo Antônio de Jesus (BA), Brazil.
| | - Marcio Galvão Oliveira
- BPharm, PhD. Evidence-Based Healthcare Professor, Master's Program on Collective Health, Multidisciplinary Health Institute, Anísio Teixeira Campus, Universidade Federal da Bahia, Vitória da Conquista (BA), Brazil.
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Jungo KT, Streit S, Lauffenburger JC. Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications. Arch Gerontol Geriatr 2020; 93:104326. [PMID: 33516154 DOI: 10.1016/j.archger.2020.104326] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/19/2020] [Accepted: 12/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions. OBJECTIVE To investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time. METHODS This retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost. RESULTS ≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs. CONCLUSION The utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.
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Affiliation(s)
- Katharina Tabea Jungo
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Korenvain C, MacKeigan LD, Dainty KN, Guilcher SJ, McCarthy LM. Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel. Res Social Adm Pharm 2020; 16:1746-1753. [DOI: 10.1016/j.sapharm.2020.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 01/05/2023]
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Gagnon ME, Sirois C, Simard M, Roux B, Plante C. Potentially inappropriate medications in older individuals with diabetes: A population-based study in Quebec, Canada. Prim Care Diabetes 2020; 14:529-537. [PMID: 32402848 DOI: 10.1016/j.pcd.2020.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 02/06/2020] [Accepted: 03/26/2020] [Indexed: 12/21/2022]
Abstract
AIM To study the population-based prevalence of potentially inappropriate medication (PIM) among older individuals with diabetes, and to identify factors associated with their use. METHODS We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS) database to conduct a population-based cohort study of individuals with diabetes ≥66 years between April 1st, 2014 and March 31st, 2015. PIMs were defined according to the 2015 Beers Criteria. Factors associated with PIM use were identified using robust Poisson regression models. Risk ratios (RR) and 99% confidence intervals (99%CI) were calculated. RESULTS More than half (56%) of the 286,962 older individuals with diabetes used at least one PIM over a year. Benzodiazepines (41%), proton pump inhibitors (27%) and endocrine medication (mainly glibenclamide) (25%) were the most common PIMs used. Factors associated with PIM use included female sex (RR: 1.17; 99%CI: 1.16-1.18), and comorbidities such as schizophrenia (1.48; 1.45-1.51), anxiety disorders (1.34; 1.33-1.35) and Alzheimer's disease (1.14; 1.13-1.25). Risks of using PIMs increased both with increasing comorbidities and number of medications. CONCLUSION PIM use is highly prevalent among older individuals with diabetes. Interventions to promote optimal medication use should particularly target individuals with comorbidities and polypharmacy who are most vulnerable to adverse drug events.
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Affiliation(s)
- Marie-Eve Gagnon
- Department of Social and Preventive Medicine, 1050 ave de la Médecine, Université Laval, Québec G1V 0A6, Canada; Institut national de santé publique du Québec, 945 ave Wolfe, Québec G1V 5B3, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, 1050 ave de la Médecine, Université Laval, Québec G1V 0A6, Canada; Institut national de santé publique du Québec, 945 ave Wolfe, Québec G1V 5B3, Canada; Centre d'Excellence sur le Vieillissement de Québec, 1050 Chemin Ste-Foy, Local L2-28, Québec G1S 4L8, Canada.
| | - Marc Simard
- Institut national de santé publique du Québec, 945 ave Wolfe, Québec G1V 5B3, Canada
| | - Barbara Roux
- Pharmacology-Toxicology and Pharmacovigilance Department, University Hospital of Limoges, 2 ave Martin-Luther-King, 87042 Limoges, France; INSERM UMR 1248, University of Limoges, Limoges, France
| | - Céline Plante
- Institut national de santé publique du Québec, 945 ave Wolfe, Québec G1V 5B3, Canada
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Awad A, Alhadab A, Albassam A. Medication-Related Burden and Medication Adherence Among Geriatric Patients in Kuwait: A Cross-Sectional Study. Front Pharmacol 2020; 11:1296. [PMID: 32973523 PMCID: PMC7472566 DOI: 10.3389/fphar.2020.01296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/05/2020] [Indexed: 12/23/2022] Open
Abstract
The evaluation of medicines burden from the patients’ perspectives is a crucial endeavor to identify any barriers that may hinder achieving optimal health outcomes. Therefore, this study was designed, firstly to identify the prevalence of medication-related burden among geriatrics and factors influencing this burden. Secondly, to determine the prevalence of medication adherence and the correlation between the burden and adherence. A cross-sectional study was performed using Living with Medicines Questionnaire version-3 (LMQ-3) and Adherence to Refills and Medications Scale (ARMS) questionnaire. Four hundred and fifty patients attending primary healthcare centers were invited to participate, and 424 (94.2%) agreed. Data were collected via face-to-face structured interviews. The vast majority of respondents (97.4%; 95% CI: 95.3–98.6) perceived to suffer from minimum (35.4%) to moderate (62.0%) degrees of medicine burden. The median (IQR) LMQ overall score was 112 (21) indicating a moderate burden. LMQ-3 overall scores revealed a significant trend toward higher perceived burden among respondents aged ≥ 75 years, males, non-Kuwaitis, residents in Al-Farwaniyah and Al-Jahra governorates, using oral and nonoral formulations, paying prescription charges, and needing support with using medicines (p <0.05). Almost 55% (95% CI: 49.8–59.5) of respondents were nonadherent to their medications. The median (IQR) ARMS overall score was 20 (7.0) indicating low adherence to medications. There was a significant positive correlation between LMQ-3 and ARMS scores (p<0.001) showing that the higher the medications burden the lower the level of medication adherence. The key findings of this study underscore the need for multifaceted interventions that could be targeted at the identified problems to reduce medication burden and improve medication adherence.
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Affiliation(s)
- Abdelmoneim Awad
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Anwar Alhadab
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Abdullah Albassam
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
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Molnar AO, Bota S, Jeyakumar N, McArthur E, Battistella M, Garg AX, Sood MM, Brimble KS. Potentially inappropriate prescribing in older adults with advanced chronic kidney disease. PLoS One 2020; 15:e0237868. [PMID: 32818951 PMCID: PMC7444541 DOI: 10.1371/journal.pone.0237868] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022] Open
Abstract
Background Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. Methods Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. Results There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. Conclusions Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.
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Affiliation(s)
- Amber O. Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- * E-mail:
| | | | | | | | - Marisa Battistella
- University Health Network/Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Manish M. Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K. Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Ayalew MB, Dieberg G, Quirk F, Spark MJ. Potentially inappropriate prescribing for adults with diabetes mellitus: a scoping review protocol. JBI Evid Synth 2020; 18:1557-1565. [PMID: 32813395 DOI: 10.11124/jbisrir-d-19-00136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This scoping review aims to explore and map studies investigating potentially inappropriate prescribing (PIP) for adults with diabetes mellitus. INTRODUCTION Inappropriate prescribing for people with diabetes mellitus has been reported by various authors focusing on different aspects of inappropriateness. A preliminary search revealed no published reviews on PIP for adults with diabetes mellitus. As a result, it is difficult to obtain a comprehensive map of PIP in this patient group. INCLUSION CRITERIA This scoping review will consider all studies on PIP for adults with the diagnosis of type 1 or type 2 diabetes mellitus from any clinical setting. Studies conducted in pediatric populations or in adults with pre-diabetes or gestational diabetes will be excluded. METHODS A three-step search strategy (i.e. an initial limited search in PubMed and ProQuest Central databases, a main search of eight databases and gray literature, and manual searches of reference lists of included articles) will be utilized. No language restrictions will be applied. All retrieved articles will be screened against the inclusion/exclusion criteria at title, abstract, and full-text stages. Data to be extracted from each study will include, but not be limited to, country, objective, study population, study methodology, type of PIP studied, examples of PIP events, medications involved, and criteria used for PIP identification. Data will be extracted by study team members using an online application for conducting systematic synthesis of evidence.
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Affiliation(s)
- Mohammed B Ayalew
- 1Department of Pharmacy, School of Rural Medicine, University of New England, Armidale, Australia 2Department of Clinical Pharmacy, School of Pharmacy, University of Gondar, Gondar, Ethiopia 3Biomedical Science, School of Science and Technology, University of New England, Armidale, Australia 4New England Institute of Healthcare Research, Faculty of Medicine and Health, University of New England, Armidale, Australia
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Shaw J, Murphy AL, Turner JP, Gardner DM, Silvius JL, Bouck Z, Gordon D, Tannenbaum C. Policies for Deprescribing: An International Scan of Intended and Unintended Outcomes of Limiting Sedative-Hypnotic Use in Community-Dwelling Older Adults. ACTA ACUST UNITED AC 2020; 14:39-51. [PMID: 31322113 PMCID: PMC7008681 DOI: 10.12927/hcpol.2019.25857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.
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Affiliation(s)
- James Shaw
- Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Andrea L Murphy
- Associate Professor, College of Pharmacy, Dalhousie University, Halifax, NS
| | - Justin P Turner
- Graduate Student, Centre de Recherche Institut Universitaire de Gériatrie de Montréal, Montreal, QC
| | - David M Gardner
- Professor, Department of Psychiatry, Dalhousie University, Halifax, NS
| | - James L Silvius
- Co-Director, Canadian Deprescribing Network; Associate Professor, Department of Medicine, University of Calgary, Calgary, AB
| | - Zachary Bouck
- Biostatistician, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Dara Gordon
- Research Coordinator, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Cara Tannenbaum
- Co-Director, Canadian Deprescribing Network; Professor, Faculties of Medicine and Pharmacy Université de Montréal, Montreal, QC
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Khera S, Abbasi M, Dabravolskaj J, Sadowski CA, Yua H, Chevalier B. Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care. J Prim Care Community Health 2020; 10:2150132719890227. [PMID: 31808725 PMCID: PMC6900606 DOI: 10.1177/2150132719890227] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Older persons with frailty take multiple medications and
are vulnerable to inappropriate prescribing. Objective: This study
assesses the impact of a team-based, pharmacist-led structured medication review
process in primary care on the appropriateness of medications taken by older
adults living with frailty. Methods: This was a quasi-experimental
pretest-posttest design in 6 primary care practices within an academic clinic in
Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years
and older with frailty who have polypharmacy and/or 2 or more chronic conditions
(ie, high-risk group for drug-related issues). The intervention was a structured
pharmacist-led medication review using evidence-based explicit criteria (ie,
Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise)
for potentially inappropriate prescribing, done in the context of a primary care
team-based seniors’ program. We measured the changes in the number of
medications pre- and postmedication review, number of medications satisfying
explicit criteria of START and STOPP/Beers and determined the association with
frailty level. Data were analyzed using descriptive and inferential statistics
(a priori significance level of P < .05).
Results: A total of 54 participants (61.1% females, mean age
81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants
completed the medication review process (2 lost to hospitalization).
Drug-related problems noted on medication review were untreated conditions
(61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No
significant changes in total number of medications taken by patients before and
after, but the intervention significantly decreased number of inappropriate
medications (1.15 meds pre to 0.9 meds post; P = .006).
Conclusion: A pharmacist-led medication review is a strategy
that can be implemented in primary care to address inappropriate
medications.
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Affiliation(s)
- Sheny Khera
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | - Hannah Yua
- Edmonton Oliver Primary Care Network, Edmonton, Alberta, Canada
| | - Bernadette Chevalier
- University of Alberta, Edmonton, Alberta, Canada.,University of Queensland, Brisbane, Queensland, Australia
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