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Green AR, Jiang R, Weston SA, Chamberlain AM, Nothelle S, Boyd CM, Rocca WA, St Sauver JL. Medication regimen complexity among community-dwelling older adults with incident mild cognitive impairment or dementia. J Am Geriatr Soc 2024. [PMID: 38511683 DOI: 10.1111/jgs.18877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/05/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Ariel R Green
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ruoxiang Jiang
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan A Weston
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Alanna M Chamberlain
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie Nothelle
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Walter A Rocca
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Women's Health Research Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Green AR, Quiles R, Daddato AE, Merrey J, Weffald L, Gleason K, Xue QL, Swarthout M, Feeser S, Boyd CM, Wolff JL, Blinka MD, Libby AM, Boxer RS. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc 2024. [PMID: 38488757 DOI: 10.1111/jgs.18867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed. METHODS A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). RESULTS 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. CONCLUSION Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalphie Quiles
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea E Daddato
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | | | - Linda Weffald
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Kaiser Permanente Colorado Institute for Health Research, Aurora, Colorado, USA
| | - Qian-Li Xue
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott Feeser
- Johns Hopkins Community Physicians, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marcela D Blinka
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Center on Aging and Health, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anne M Libby
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Davis Department of Medicine, University of California, Sacramento, California, USA
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Lu Y, Green AR, Quiles R, Taylor CO. An Automated Strategy to Calculate Medication Regimen Complexity. AMIA Annu Symp Proc 2024; 2023:1077-1086. [PMID: 38222413 PMCID: PMC10785893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Understanding medication regimen complexity is important to understand what patients may benefit from pharmacist interventions. Medication Regimen Complexity Index (MRCI), a 65-item tool to quantify the complexity by incorporating the count, dosage form, frequency, and additional administration instructions of prescription medicines, provides a more nuanced way of assessing complexity. The goal of this study was to construct and validate a computational strategy to automate the calculation of MRCI. The performance of our strategy was evaluated by comparing our calculated MRCI values with gold-standard values, using correlation coefficients and population distributions. The results revealed satisfactory performance to calculate the sub-score of MRCI that includes dosage form and frequency (76 to 80% match with gold standard), and fair performance for sub-score related to additional direction (52% match with gold standard). Our automated strategy shows potential to help reduce the effort for manually calculating MRCI and highlights areas for future development efforts.
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Affiliation(s)
- Yuzhi Lu
- Johns Hopkins University Whiting School of Engineering, Department of Biomedical Engineering, Baltimore, MD
| | - Ariel R Green
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, MD
| | - Rosalphie Quiles
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, MD
| | - Casey Overby Taylor
- Johns Hopkins University Whiting School of Engineering, Department of Biomedical Engineering, Baltimore, MD
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Boyd CM, Shetterly SM, Powers JD, Weffald LA, Green AR, Sheehan OC, Reeve E, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Maciejewski ML, Wolff JL, Kraus C, Bayliss EA. Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial. Drugs Aging 2024; 41:45-54. [PMID: 37982982 DOI: 10.1007/s40266-023-01080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. METHODS This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. RESULTS There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. CONCLUSIONS Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. TRIAL REGISTRATION NCT03984396. Registered on 13 June 2019.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - John D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Green AR, Weffald LA, Powers JD, Drace ML, Norton JD, Boyd CM, Bayliss EA. Assessing medication appropriateness as a deprescribing outcome. J Am Geriatr Soc 2023; 71:3918-3920. [PMID: 37632424 PMCID: PMC10987076 DOI: 10.1111/jgs.18562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/19/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Ariel R. Green
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, MD
| | - Linda A. Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO
| | - John D. Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jonathan D. Norton
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, MD
| | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, MD
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
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Gleason KT, Wu MMJ, Wec A, Powell DS, Zhang T, Gamper MJ, Green AR, Nothelle S, Amjad H, Wolff JL. Use of the patient portal among older adults with diagnosed dementia and their care partners. Alzheimers Dement 2023; 19:5663-5671. [PMID: 37354066 PMCID: PMC10808947 DOI: 10.1002/alz.13354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/29/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Care partners are at the forefront of dementia care, yet little is known about patient portal use in the context of dementia diagnosis. METHODS We conducted an observational cohort study of date/time-stamped patient portal use for a 5-year period (October 3, 2017-October 2, 2022) at an academic health system. The cohort consisted of 3170 patients ages 65+ with diagnosed dementia with 2+ visits within 24 months. Message authorship was determined by manual review of 970 threads involving 3065 messages for 279 patients. RESULTS Most (71.20%) older adults with diagnosed dementia were registered portal users but far fewer (10.41%) had a registered care partner with shared access. Care partners authored most (612/970, 63.09%) message threads, overwhelmingly using patient identity credentials (271/279, 97.13%). DISCUSSION The patient portal is used by persons with dementia and their care partners. Organizational efforts that facilitate shared access may benefit the support of persons with dementia and their care partners. Highlights Patient portal registration and use has been increasing among persons with diagnosed dementia. Two thirds of secure messages from portal accounts of patients with diagnosed dementia were identified as being authored by care partners, primarily using patient login credentials. Care partners who accessed the patient portal using their own identity credentials through shared access demonstrate similar levels of activity to patients without dementia. Organizational initiatives should recognize and support the needs of persons with dementia and their care partners by encouraging awareness, registration, and use of proper identity credentials, including shared, or proxy, portal access.
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Affiliation(s)
- Kelly T. Gleason
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Mingche M. J. Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aleksandra Wec
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danielle S. Powell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Talan Zhang
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Jo Gamper
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L. Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open 2023; 6:e2336728. [PMID: 37787993 PMCID: PMC10548310 DOI: 10.1001/jamanetworkopen.2023.36728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. Objective To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. Design, Setting, and Participants A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. Main Outcomes and Measures The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. Results A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Conclusions and Relevance Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.
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Affiliation(s)
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Nicole Williams
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia
| | - Matthew K. Wynia
- University of Colorado Center for Bioethics and Humanities, Anschutz Medical Campus, Aurora
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Policy and Management, Colorado School of Public Health, Aurora
| | - Ariel R. Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lee JW, Jeong S, Han HR, Boyd CM, Perrin N, Simmons SF, Green AR, Taylor JL, Boucher HR, Szanton SL. Barriers and facilitators to deprescribing before surgery: A qualitative study of providers and older adults. Geriatr Nurs 2023; 53:135-140. [PMID: 37540907 PMCID: PMC10528381 DOI: 10.1016/j.gerinurse.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/22/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION Deprescribing, the collaborative process between providers and patients to streamline medication regimen, may reduce the risk of adverse events following surgery among older adults with multimorbidity. However, barriers and facilitators to deprescribing for surgery has not been explored. METHODS We conducted a qualitative study of Primary Care Providers (PCP) and patients aged 65 and older who were scheduled for surgery. We used the Theoretical Domains Framework, which informed the interview guide and analysis. RESULTS A total of 16 participants (n=8 providers, n=8 patients) were included. Themes were regarding: 1) attitudes towards deprescribing before surgery, 2) perceived benefits of deprescribing before surgery, 3) patient-provider relationship and shared decision-making, 4) hope for surgery, 5) barriers to deprescribing before surgery, and 6) preferences for deprescribing follow-up. CONCLUSION Our study findings regarding provider- and patient-related barriers and facilitators for deprescribing and desired processes before surgery may inform future deprescribing intervention targets before surgery.
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Affiliation(s)
- Ji Won Lee
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205.
| | - Suin Jeong
- Medstar Georgetown University, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Hae-Ra Han
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205
| | - Cynthia M Boyd
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3(rd) Floor, Baltimore, MD, 21224
| | - Nancy Perrin
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205
| | - Sandra Faye Simmons
- Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Division of Geriatrics, Nashville, TN, USA; VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN, USA
| | - Ariel R Green
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3(rd) Floor, Baltimore, MD, 21224
| | - Janiece L Taylor
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205
| | - Henry R Boucher
- Medstar Union Memorial Hospital, 3333 N. Calvert St. Suite 400, Baltimore, MD, 21218
| | - Sarah L Szanton
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205
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Sheehan OC, Gleason KS, Bayliss EA, Green AR, Drace ML, Norton J, Reeve E, Shetterly SM, Weffald LA, Sawyer JK, Maciejewski ML, Kraus C, Maiyani M, Wolff J, Boyd CM. Intervention design in cognitively impaired populations-Lessons learned from the OPTIMIZE deprescribing pragmatic trial. J Am Geriatr Soc 2023; 71:774-784. [PMID: 36508725 DOI: 10.1111/jgs.18148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/08/2022] [Accepted: 10/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions, increasing risks of adverse drug events, hospitalization, and death. Deprescribing, the process of reducing or stopping potentially inappropriate medications, may improve outcomes. The OPTIMIZE pragmatic trial examined whether educating and activating patients, family members and clinicians about deprescribing reduces number of chronic medications and potentially inappropriate medications. Acceptability and challenges of intervention delivery in cognitively impaired older adults are not well understood. METHODS We explored mechanisms of intervention implementation through post hoc qualitative interviews and surveys with stakeholder groups of 15 patients, 7 caregivers, and 28 clinicians. We assessed the context in which the intervention was delivered, its implementation, and mechanisms of impact. RESULTS Acceptance of the intervention was affected by contextual factors including cognition, prior knowledge of deprescribing, communication, and time constraints. All stakeholder groups endorsed the acceptability, importance, and delivery of the intervention. Positive mechanisms of impact included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials was inconsistent but most likely shortly after intervention delivery. Short visit times remained the largest provider barrier to deprescribing. CONCLUSIONS Our work identifies key learnings in intervention delivery that can guide future scaling of deprescribing interventions in this population. We highlight the critical roles of timing and repetition in intervention delivery to cognitively impaired populations and the barrier posed by short consultation times. The acceptability of the intervention to patients and family members highlights the potential to incorporate deprescribing education into routine clinical practice and expand proven interventions to other vulnerable populations.
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Affiliation(s)
- Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Geriatric Medicine, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jonathan Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jennifer Wolff
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Reeve E, Bayliss EA, Shetterly S, Maiyani M, Gleason KS, Norton JD, Sheehan OC, Green AR, Maciejewski ML, Drace M, Sawyer J, Boyd CM. Willingness of older people living with dementia and mild cognitive impairment and their caregivers to have medications deprescribed. Age Ageing 2023; 52:6998044. [PMID: 36702513 PMCID: PMC9879708 DOI: 10.1093/ageing/afac335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/04/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND people living with cognitive impairment commonly take multiple medications including potentially inappropriate medications (PIMs), which puts them at risk of medication related harms. AIMS to explore willingness to have a medication deprescribed of older people living with cognitive impairment (dementia or mild cognitive impairment) and multiple chronic conditions and assess the relationship between willingness, patient characteristics and belief about medications. METHODS cross-sectional study using results from the revised Patients' Attitudes Towards Deprescribing questionnaire (rPATDcog) collected as baseline data in the OPTIMIZE study, a pragmatic, cluster-randomised trial educating patients and clinicians about deprescribing. Eligible participants were 65+, diagnosed with dementia or mild cognitive impairment, and prescribed at least five-long-term medications. RESULTS the questionnaire was mailed to 1,409 intervention patients and 553 (39%) were returned and included in analysis. Participants had a mean age of 80.1 (SD 7.4) and 52.4% were female. About 78.5% (431/549) of participants said that they would be willing to have one of their medications stopped if their doctor said it was possible. Willingness to deprescribe was negatively associated with getting stressed when changes are made and with previously having a bad experience with stopping a medication (P < 0.001 for both). CONCLUSION most older people living with cognitive impairment are willing to deprescribe. Addressing previous bad experiences with stopping a medication and stress when changes are made to medications may be key points to discuss during deprescribing conversations.
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Affiliation(s)
- Emily Reeve
- Address correspondence to: Emily Reeve, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University (Parkville Campus), 381 Royal Parade, Parkville Victoria 3052, Australia.
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Susan Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Geriatric Medicine, RCSI Hospitals Group, Connolly Hospital, Dublin, Ireland
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Veterans Affairs Medical Center, Durham, NC, USA,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Melanie Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Wolff JL, DesRoches CM, Amjad H, Burgdorf JG, Caffrey M, Fabius CD, Gleason KT, Green AR, Lin CT, Nothelle SK, Peereboom D, Powell DS, Riffin CA, Lum HD. Catalyzing dementia care through the learning health system and consumer health information technology. Alzheimers Dement 2023; 19:2197-2207. [PMID: 36648146 PMCID: PMC10182243 DOI: 10.1002/alz.12918] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 01/18/2023]
Abstract
To advance care for persons with Alzheimer's disease and related dementias (ADRD), real-world health system effectiveness research must actively engage those affected to understand what works, for whom, in what setting, and for how long-an agenda central to learning health system (LHS) principles. This perspective discusses how emerging payment models, quality improvement initiatives, and population health strategies present opportunities to embed best practice principles of ADRD care within the LHS. We discuss how stakeholder engagement in an ADRD LHS when embedding, adapting, and refining prototypes can ensure that products are viable when implemented. Finally, we highlight the promise of consumer-oriented health information technologies in supporting persons living with ADRD and their care partners and delivering embedded ADRD interventions at scale. We aim to stimulate progress toward sustainable infrastructure paired with person- and family-facing innovations that catalyze broader transformation of ADRD care.
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Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine M DesRoches
- OpenNotes/Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julia G Burgdorf
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Melanie Caffrey
- Springer Science+Business Media LLC, Oracle Magazine, Computer Technology and Applications Program, Columbia University, New York, New York, USA
| | - Chanee D Fabius
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kelly T Gleason
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Stephanie K Nothelle
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Danielle Peereboom
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danielle S Powell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine A Riffin
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Sheehan OC, Bayliss EA, Green AR, Drace ML, Norton J, Reeve E, Shetterly SS, Gleason Kathy S, Weffald LA, Maciejewski ML, Kraus C, Maiyani M, Wolff J, Boyd CM. 263 INFORMING INTERVENTION DESIGN IN COGNITIVELY IMPAIRED POPULATIONS: LESSONS LEARNED FROM THE OPTIMIZE DEPRESCRIBING INTERVENTION. Age Ageing 2022. [DOI: 10.1093/ageing/afac218.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions increasing their risks of adverse drug events, hospitalization, further cognitive decline and death and leading to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes. The OPTIMIZE trial examined whether educating and activating patients, family and clinicians about deprescribing reduces number of medications for older adults with cognitive impairment and multiple chronic conditions. Acceptability and challenges of intervention delivery in this vulnerable population are not well understood.
Methods
We explored mechanisms of intervention effectiveness through post hoc qualitative interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. We assessed accessibility and delivery of materials as well as the ability of the materials to facilitate conversations and influence decisions around deprescribing.
Results
Acceptance of the intervention was affected by contextual factors including cognition and prior knowledge of deprescribing. Positive effects of the intervention included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials by patients was inconsistent but highest shortly after intervention delivery. Short clinic visit times remained the largest clinician barrier to deprescribing.
Conclusion
Our work identifies key learnings in intervention roll out which can guide future scaling of our intervention and other pragmatic deprescribing intervention studies in patients with cognitive impairment. We highlight the critical roles of both timing and repetition in intervention delivery to cognitively impaired populations as well as the barrier to deprescribing posed by short clinic consultation time. Our success in activating deprescribing conversations in this population highlights the need to incentivize medical professionals and health systems to incorporate deprescribing into routine clinical practice and expand proven interventions to other vulnerable populations.
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Affiliation(s)
- OC Sheehan
- Connolly Hospital RCSI Hospital Group, , Dublin, Ireland
- Johns Hopkins University School of Medicine , Baltimore, USA
| | - EA Bayliss
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - AR Green
- Johns Hopkins University School of Medicine , Baltimore, USA
| | - ML Drace
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - J Norton
- Johns Hopkins University School of Medicine , Baltimore, USA
| | - E Reeve
- University of South Australia , Adelaide, Australia
| | - SS Shetterly
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - S Gleason Kathy
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - LA Weffald
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | | | - C Kraus
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - M Maiyani
- Institute for Health Research, Kaiser Permanente , Colorado, USA
| | - J Wolff
- Johns Hopkins University School of Public Health , Baltimore, USA
| | - CM Boyd
- Johns Hopkins University School of Medicine , Baltimore, USA
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13
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Green AR, Aschmann H, Boyd CM, Schoenborn N. Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey. J Am Geriatr Soc 2022; 70:2895-2904. [PMID: 35661991 PMCID: PMC9588518 DOI: 10.1111/jgs.17917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/04/2022] [Accepted: 05/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications. METHODS A cross-sectional survey was conducted from March-April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities. RESULTS Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02-2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05-2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39-1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48-0.91]). CONCLUSIONS Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.
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Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Hélène Aschmann
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichZurichSwitzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA,Department of Health Policy and ManagementJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Nancy Schoenborn
- Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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14
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Nothelle S, Chamberlain AM, Jacobson D, Green AR, Boyd CM, Rocca WA, Fan C, St. Sauver JL. Prevalence of co-occurring serious illness diagnoses and association with health care utilization at the end of life. J Am Geriatr Soc 2022; 70:2621-2629. [PMID: 35593458 PMCID: PMC9489605 DOI: 10.1111/jgs.17881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION End-of-life care differs by serious illness diagnosis. Cancer and dementia are serious illnesses that have been associated with less intensive end-of-life health care use. It is not known how health care utilization varies in the presence of >1 serious illness. METHODS We used the Rochester Epidemiology Project to identify persons living in a midwestern area who died on July 1, 2017-June 30, 2018 at age ≥65 years, and were seriously ill. We examined the number of emergency department (ED), hospital, and intensive care unit (ICU) stays in the last 6 months and the last 30 days of life. We used Poisson regression to determine the incidence rate ratio for ED, hospital, and ICU stay in the last 6 months and 30 days of life by number of serious illness diagnoses. For cancer and dementia, we examined the effect of an additional serious illness. RESULTS We included a population of 1372 adults who were, on average, 84 years, 52% female, and 96% white. Approximately 41% had multiple serious illnesses. Compared to older adults with 1 serious illness diagnosis, rates of hospitalization, and ICU stay for adults with 2 or ≥3 serious illness diagnoses were at least 1.5 times higher in the last 6 months and the last 30 days of life. Rates of ED visits were significantly higher for older adults with 2 or ≥3 serious illness diagnoses in the last 6 months of life, but only higher for those with ≥3 versus 1 serious illness diagnosis in the last 30 days of life. For both cancer and dementia, rates of ED visits, hospitalization and ICU stay were lower for the condition alone than when an additional serious illness diagnosis was present. CONCLUSION Having multiple serious illnesses increases the risk of health care utilization at the end of life.
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Affiliation(s)
- Stephanie Nothelle
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Alanna M. Chamberlain
- Division of Epidemiology, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
| | - Debra Jacobson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Ariel R. Green
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Cynthia M. Boyd
- Center for Transformative Geriatrics Research, Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Walter A. Rocca
- Division of Epidemiology, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA,Department of NeurologyMayo ClinicRochesterMinnesotaUSA,Women's Health Research CenterMayo ClinicRochesterMinnesotaUSA
| | - Chun Fan
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Jennifer L. St. Sauver
- Division of Epidemiology, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
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15
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Bayliss EA, Shetterly SM, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Weffald LA, Green AR, Reeve E, Maciejewski ML, Sheehan OC, Wolff JL, Kraus C, Boyd CM. Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial. JAMA Intern Med 2022; 182:534-542. [PMID: 35343999 PMCID: PMC8961395 DOI: 10.1001/jamainternmed.2022.0502] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Individuals with dementia or mild cognitive impairment frequently have multiple chronic conditions (defined as ≥2 chronic medical conditions) and take multiple medications, increasing their risk for adverse outcomes. Deprescribing (reducing or stopping medications for which potential harms outweigh potential benefits) may decrease their risk of adverse outcomes. OBJECTIVE To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment. DESIGN, SETTING, AND PARTICIPANTS This pragmatic, patient-centered, 12-month cluster randomized clinical trial was conducted from April 1, 2019, to March 31, 2020, at 18 primary care clinics in a not-for-profit integrated health care delivery system. The study included 3012 adults aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications. INTERVENTIONS An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings. MAIN OUTCOMES AND MEASURES The number of prescribed long-term medications and the percentage of individuals prescribed 1 or more potentially inappropriate medications (PIMs). Analysis was performed on an intention-to-treat basis. RESULTS This study comprised 1433 individuals (806 women [56.2%]; mean [SD] age, 80.1 [7.2] years) in 9 intervention clinics and 1579 individuals (874 women [55.4%]; mean [SD] age, 79.9 [7.5] years) in 9 control clinics who met the eligibility criteria. At baseline, both groups were prescribed a similar mean (SD) number of long-term medications (7.0 [2.1] in the intervention group and 7.0 [2.2] in the control group), and a similar proportion of individuals in both groups were taking 1 or more PIMs (437 of 1433 individuals [30.5%] in the intervention group and 467 of 1579 individuals [29.6%] in the control group). At 6 months, the adjusted mean number of long-term medications was similar in the intervention and control groups (6.4 [95% CI, 6.3-6.5] vs 6.5 [95% CI, 6.4-6.6]; P = .14). The estimated percentages of patients in the intervention and control groups taking 1 or more PIMs were similar (17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = .08). In preplanned subgroup analyses, adjusted differences between the intervention and control groups were -0.16 (95% CI, -0.34 to 0.01) for individuals prescribed 7 or more long-term medications at baseline (n = 1434) and -0.03 (95% CI, -0.20 to 0.13) for those prescribed 5 to 6 medications (n = 1578) (P = .28 for interaction; P = .19 for subgroup interaction for PIMs). CONCLUSIONS AND RELEVANCE This large-scale educational deprescribing intervention for older adults with cognitive impairment taking 5 or more long-term medications and their primary care clinicians demonstrated small effect sizes and did not significantly reduce the number of long-term medications and PIMs. Such interventions should target older adults taking relatively more medications. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03984396.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora.,Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, South Australia, Australia
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, North Carolina.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer L Wolff
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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McNabney MK, Green AR, Burke M, Le ST, Butler D, Chun AK, Elliott DP, Fulton AT, Hyer K, Setters B, Shega JW. Complexities of care: Common components of models of care in geriatrics. J Am Geriatr Soc 2022; 70:1960-1972. [PMID: 35485287 PMCID: PMC9540486 DOI: 10.1111/jgs.17811] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 12/29/2022]
Abstract
As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this “care complexity.” Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.
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Affiliation(s)
| | - Ariel R Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Meg Burke
- Geriatric Medicine Associates, Westminster, Colorado, USA
| | - Stephanie T Le
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dawn Butler
- Indiana University, Indianapolis, Indiana, USA
| | - Audrey K Chun
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Kathryn Hyer
- University of South Florida, Tampa, Florida, USA
| | | | - Joseph W Shega
- University of Central Florida, Gotha, Florida, USA.,VITAS Healthcare, Gotha, Florida, USA
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17
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Lee JW, Li M, Boyd CM, Green AR, Szanton SL. Preoperative Deprescribing for Medical Optimization of Older Adults Undergoing Surgery: A Systematic Review. J Am Med Dir Assoc 2021; 23:528-536.e2. [PMID: 34861224 DOI: 10.1016/j.jamda.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To summarize the evidence for preoperative deprescribing and its effect on postoperative outcomes in older adults undergoing surgery. DESIGN Systematic review. SETTING AND PARTICIPANTS All available studies. METHODS We searched EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), and PubMed from inception to January 12, 2021. Settings included outpatient settings during the waiting period for surgery (ie, preoperative clinic) through to the preoperative period in the hospital. Participants who were older adults, aged ≥65 years, undergoing planned or emergency surgery with deprescribing or medication-related interventions were included for review. RESULTS We identified 3 different methods of deprescribing intervention delivery during the preoperative period: geriatrician-led (n = 2), interdisciplinary team-led (n = 8), and pharmacist-led (n = 6). Outcomes were related to health care utilization, patient outcomes, and medication changes; however, results were difficult to compare because of heterogeneous outcomes within the topics. Overall, results were either positive or neutral. CONCLUSIONS AND IMPLICATIONS The evidence for deprescribing during the preoperative period for older adults undergoing surgery is weak because of the heterogeneity of intervention delivery and outcomes, inclusion of nonoperative cases in some studies, and low power. This review highlights the need for future research, which may consider the following: (1) interdisciplinary approach, (2) coordination of deprescribing efforts with primary care provider from the waiting period for surgery up to after hospital discharge, and (3) validated deprescribing criteria such as STOPP/START that is easy to implement. It is important to note that results yielded positive and neutral results, not negative ones, which should reassure clinicians to implement deprescribing for older adults during the surgical period. Additionally, policy initiatives such as integrated electronic medical records or increased reimbursement of deprescribing efforts for primary care providers and/or hospitals should be pursued to prevent adverse postoperative events for this population.
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Affiliation(s)
- Ji Won Lee
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.
| | - Mengchi Li
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | - Ariel R Green
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sarah L Szanton
- Johns Hopkins University School of Nursing, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Parks RM, Green AR, Cheung KL. O14 Optimising the management of primary breast cancer in older women. Br J Surg 2021. [DOI: 10.1093/bjs/znab282.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
The risk of breast cancer increases with age and our global population is ageing. By 2040 the number of breast cancer cases diagnosed per year worldwide will double and over 40% of these will be in patients aged 70 or over. Despite this, there are few treatment guidelines specific to breast cancer in older women and none which consider the unique biological differences of this cohort.
Method
Surgical and core needle biopsy (CNB) specimens were obtained from an existing series of 1,785 women over the age of 70 with primary breast cancer, treated in a single institution with long-term (37+ years) follow-up. Of this cohort, 813 had primary surgical treatment. As part of previous work, it was possible to construct good quality tissue microarrays (TMAs) in 575 surgical specimens and 693 CNB specimens. Immunohistochemical staining for 32 biomarkers has been performed in all of the available TMAs. Association between histological score for each biomarker and tumour size, grade, recurrence rate, breast cancer specific and overall survival is currently being investigated in the whole cohort.
Results
Results to date have revealed a unique biological cluster in older women with primary breast cancer that is not seen in a comparative younger cohort. In the future, bioinformatics analysis will determine which biomarkers and in what combination, can predict chance of recurrence/overall survival in this cohort.
Conclusions
This information will be used to create a prognostic tool specific to assist older women with decision making regarding primary treatment of breast cancer.
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Affiliation(s)
- R M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - A R Green
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - K L Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Parks RM, Alfarsi LH, Green AR, Cheung KL. Biology of primary breast cancer in older women beyond routine biomarkers. Breast Cancer 2021; 28:991-1001. [PMID: 34165702 PMCID: PMC8354915 DOI: 10.1007/s12282-021-01266-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/13/2021] [Indexed: 11/15/2022]
Abstract
Purpose There are numerous biomarkers which may have potential predictive and prognostic significance in breast cancer. This is extremely important in older adults, who may opt for less aggressive therapy. This work outlines the literature on biological assessment outside of standard biomarkers (defined as ER, PgR, HER2, Ki67) in women ≥ 65 years with primary operable invasive breast cancer, to determine which additional biomarkers are relevant to outcome in older women. Methods Medline and Embase databases were searched. Studies were eligible if included ≥ 50 patients aged ≥ 65 years; stratified results by age; measured a biomarker outside of standard assay and reported patient data. Results A total of 12 studies were appraised involving 5000 patients, measuring 28 biomarkers. The studies were extremely varied in methodology and outcome but three themes emerged: 1. Differences in biomarker expression between younger and older women, indicating that breast cancer in older women is generally less aggressive compared to younger women; 2. Relationship of biomarker expression with survival, suggesting biomarkers which may exclusively predict response to primary treatment in older women; 3. Association of biomarker with chemotherapy, suggesting that older patients should not be declined chemotherapy based on age alone. Conclusion There is evidence to support further investigation of B-cell lymphoma (BCL2), liver kinase (LK)B1, epidermal growth factor receptor (EGFR), cytoplasmic cyclin-E, mucin (MUC)1 and cytokeratins (CKs) as potential predictive or prognostic markers in older women with breast cancer undergoing surgery. Studies exploring these biomarkers in larger cohorts and in women undergoing non-operative therapies are required. Supplementary Information The online version contains supplementary material available at 10.1007/s12282-021-01266-5.
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Affiliation(s)
- R M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
| | - L H Alfarsi
- Nottingham Breast Cancer Research Centre, School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
| | - A R Green
- Nottingham Breast Cancer Research Centre, School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK
| | - K L Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Uttoxeter Road, Derby, DE22 3DT, UK.
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20
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Stebbing J, Zhang H, Xu Y, Lit LC, Green AR, Grothey A, Lombardo Y, Periyasamy M, Blighe K, Zhang W, Shaw JA, Ellis IO, Lenz HJ, Giamas G. Correction to: KSR1 regulates BRCA1 degradation and inhibits breast cancer growth. Oncogene 2021; 40:3473. [PMID: 33888869 DOI: 10.1038/s41388-021-01759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- J Stebbing
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - H Zhang
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - Y Xu
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - L C Lit
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK.,Faculty of Medicine, Department of Physiology, University of Malaya, Kuala, Lumpur, Malaysia
| | - A R Green
- Department of Cellular Pathology, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - A Grothey
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - Y Lombardo
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - M Periyasamy
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - K Blighe
- Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - W Zhang
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Centre, Keck School of Medicine, Los Angeles, CA, USA
| | - J A Shaw
- Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - I O Ellis
- Faculty of Medicine, Department of Physiology, University of Malaya, Kuala, Lumpur, Malaysia
| | - H J Lenz
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Centre, Keck School of Medicine, Los Angeles, CA, USA
| | - G Giamas
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK.
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21
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Abstract
IMPORTANCE How clinicians communicate about deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, may be associated with the extent to which older adults are willing to do it. OBJECTIVE To examine older adults' preferences regarding different rationales a clinician may use to explain why a patient should stop an unnecessary or potentially harmful medication. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey study was conducted from March 25 to April 19, 2020, among a nationally representative, probability-based online survey panel (KnowledgePanel). KnowledgePanel members aged 65 years and older were recruited by random digit dialing and address-based sampling. Data were analyzed from May 4 to July 8, 2020. EXPOSURES The survey presented 2 vignettes involving hypothetical older adults. One described a statin being used for primary prevention by a person with functional impairment and polypharmacy. The second described a sedative-hypnotic, such as zolpidem, being used for insomnia by a person with good functional status. MAIN OUTCOMES AND MEASURES After each vignette, participants expressed preferences using a best-worst scaling method for 7 different phrases a clinician may use to explain why they should reduce or stop the medication. Conditional logistic regression was used to quantify respondents' relative preferences. RESULTS A total of 1193 KnowledgePanel members were invited, and 835 respondents (70.0%) completed the survey. The mean (SD) age was 73 (6) years, 414 (49.6%) were women, and 671 (80.4%) self-identified as White individuals. A total of 496 respondents (59.8%) had ever used a statin, and 124 respondents (14.9%) had ever used a sedative-hypnotic. For both medications, the most preferred phrase to explain deprescribing focused on the risk of side effects. For statins, this phrase was 5.8-fold (95% CI, 5.3-6.3) more preferred than the least preferred option, which focused on the effort (treatment burden) involved in taking the medicine. For sedative-hypnotics, the phrase about side effects was 8.6-fold (95% CI, 7.9-9.5) more preferred over the least preferred option, "This medicine is unlikely to help you function better." CONCLUSIONS AND RELEVANCE These findings suggest that among older adults, the most preferred rationale for deprescribing both preventive and symptom-relief medicines focused on the risk of side effects. These results could be used to inform clinical practice and improve effective communications around deprescribing in older adults.
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Affiliation(s)
- Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hélène Aschmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Nancy Schoenborn
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Green AR, Boyd CM, Gleason KS, Wright L, Kraus CR, Bedoy R, Sanchez B, Norton J, Sheehan OC, Wolff JL, Reeve E, Maciejewski ML, Weffald LA, Bayliss EA. Perspectives on Deprescribing Communication in Primary Care. J Gen Intern Med 2021; 36:1122. [PMID: 33432430 PMCID: PMC8042063 DOI: 10.1007/s11606-020-06377-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Courtney R Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ruth Bedoy
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Bianca Sanchez
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Norton
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer L Wolff
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, SA, Adelaide, Australia
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Green AR, Boyd CM, Gleason KS, Wright L, Kraus CR, Bedoy R, Sanchez B, Norton J, Sheehan OC, Wolff JL, Reeve E, Maciejewski ML, Weffald LA, Bayliss EA. Designing a Primary Care-Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study. J Gen Intern Med 2020; 35:3556-3563. [PMID: 32728959 PMCID: PMC7728901 DOI: 10.1007/s11606-020-06063-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events. OBJECTIVES To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing. DESIGN Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians. PARTICIPANTS Patients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations. APPROACH We used constant comparison to identify and compare themes between patients, caregivers, and physicians. KEY RESULTS We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers' expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations. CONCLUSIONS Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Courtney R Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ruth Bedoy
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Bianca Sanchez
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Norton
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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24
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Ouellet GM, Kiwak E, Costello DM, Green AR, Geda M, Naik AD, Tinetti ME. Clinician Perspectives on Incorporating Patients' Values-Based Health Priorities in Decision-Making. J Am Geriatr Soc 2020; 69:267-269. [PMID: 33165913 DOI: 10.1111/jgs.16914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/06/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Gregory M Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eliza Kiwak
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Darcé M Costello
- Program on Aging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Geda
- Program on Aging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aanand D Naik
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Medicine (Health Services Research and Geriatrics), Baylor College of Medicine, Houston, Texas, USA
| | - Mary E Tinetti
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut, USA
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25
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Bayliss EA, Shetterly SM, Drace ML, Norton J, Green AR, Reeve E, Weffald LA, Wright L, Maciejewski ML, Sheehan OC, Wolff JL, Gleason KS, Kraus C, Maiyani M, Du Vall M, Boyd CM. The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial. Trials 2020; 21:542. [PMID: 32552857 PMCID: PMC7301527 DOI: 10.1186/s13063-020-04482-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI. Methods With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions. Discussion The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC. Trial registration NCT03984396. Registered on 13 June 2019
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Affiliation(s)
- E A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA. .,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - S M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - J Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - L A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - L Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - O C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J L Wolff
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - K S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - C Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M Du Vall
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - C M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Green AR, Wolff JL, Echavarria DM, Chapman M, Phung A, Smith D, Boyd CM. How Clinicians Discuss Medications During Primary Care Encounters Among Older Adults with Cognitive Impairment. J Gen Intern Med 2020; 35:237-246. [PMID: 31705465 PMCID: PMC6957586 DOI: 10.1007/s11606-019-05424-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/19/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use. OBJECTIVE To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions. DESIGN Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment. Visits occurred between August 2016 and August 2017. PARTICIPANTS Patients were 65 or older, had > 1 incorrect answer on a cognitive screener, and attended visits with a relative or unpaid companion. Clinicians were physicians, nurse practitioners, or physician assistants at participating practices. APPROACH The encounters were transcribed verbatim. We used qualitative content analysis to identify major themes. KEY RESULTS Patients were on average 79.9 years of age. The average MMSE score was 21.6. About half of clinicians reported practicing for 15 or more years (n = 8). We identified three major themes. First, we found numerous instances in which primary care clinicians introduced patients and companions to key principles of optimal prescribing and deprescribing. Second, clinicians used a variety of approaches to foster shared decision-making about medication use. Third, several challenges prevented clinicians from working together with patients and companions to optimize prescribing and deprescribing. CONCLUSIONS This study offers insight into key language clinicians can use to initiate discussions about optimizing prescribing, as well as barriers they face in doing so. Examples identified in these transcripts should be tested with patients and caregivers to examine how such communications are received and interpreted. Future research should develop and test interventions that seek to overcome obstacles to optimizing prescribing for older adults with cognitive impairment.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jennifer L Wolff
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Diane M Echavarria
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Malcolm Chapman
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Annie Phung
- Philadelphia College of Osteopathic Medicine - Georgia, Suwanee, GA, USA
| | - Devon Smith
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
INTRODUCTION Frailty affects 15% of non-institutionalized older adults in the United States, yet confusion remains in defining and, in turn, assessing frailty. Figurative language, such as metaphor, can help to explain difficult scientific concepts and to form new theories. We aimed to examine the use of figurative language to describe frailty and to identify themes in the way figurative expressions are used. Understanding how frailty is described figuratively may offer insights for developing useful communication approaches in research settings. METHODS We performed a comprehensive review of editorials in the scientific literature to explore figurative language used to describe frailty in older adults. We categorized themes among the figurative expressions, which may help to inform how to effectively communicate about frailty. RESULTS We found 24 editorials containing 32 figurative expressions. The figurative expressions conceptualized frailty in six ways: 1) a complex, multifaceted concept; 2) an important issue in health and medicine; 3) indicative of something that is failing or faulty; 4) indicative of fragility; 5) representative of vulnerable, ignored persons; and 6) an opportunity for self-awareness and reflection. DISCUSSION Our review highlights the heterogeneity in depictions of frailty, which is consonant with the lack of a standardized definition of frailty. We also found a novel aspect to the concept of frailty, which merits attention: frailty characterized as an opportunity for self-awareness and reflection. Figurative language, which often juxtaposes familiar with challenging, complex concepts, can offer insights on issues in frailty research and holds potential as a tool for researchers to improve communication about this important and debated medical condition.
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Affiliation(s)
- B Buta
- Brian Buta, MHS, 2024 E. Monument St., Suite 2-700, Baltimore, Maryland. Phone: 410-502-3412.
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29
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Green AR, Reifler LM, Bayliss EA, Weffald LA, Boyd CM. Drugs Contributing to Anticholinergic Burden and Risk of Fall or Fall-Related Injury among Older Adults with Mild Cognitive Impairment, Dementia and Multiple Chronic Conditions: A Retrospective Cohort Study. Drugs Aging 2019; 36:289-297. [PMID: 30652263 DOI: 10.1007/s40266-018-00630-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. OBJECTIVES Our objective was to assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. METHODS This was a retrospective cohort study of adults aged ≥ 65 years with mild cognitive impairment (MCI) or dementia and two or more additional chronic conditions (N = 10,698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the anticholinergic cognitive burden (ACB) scale, falls and fall-related injuries. RESULTS During a median follow-up of 366 days, 63% of the cohort used one or more ACB drug; 2015 (18.8%) people experienced a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when level 2 and level 3 drugs were used in combination [hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.51-2.83]. Multiple ACB level 1 drugs taken together also increased the hazard of a fall or fall-related injury (HR 1.16; 95% CI 1.03-1.32). The risk of fall or fall-related injury as a function of exposure to ACB level 2 drugs (HR 1.56; 95% CI 1.16-2.10) was higher than that for ACB level 1 or 3 drugs. CONCLUSIONS The same daily ACB score was associated with a different degree of risk, depending on the ACB ratings of the individual drugs comprising the score. Combinations of level 2 and level 3 drugs had the greatest risk of fall or fall-related injury relative to other individuals with the same daily ACB score. Low-potency anticholinergic drugs taken together modestly increased the hazard of a fall or fall-related injury.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green AR, Kelley A, Matlock D, Ouellet J, Rich MW, Schoenborn NL, Tinetti ME. Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity. J Am Geriatr Soc 2019; 67:665-673. [DOI: 10.1111/jgs.15809] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Cynthia Boyd
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | | | - Frederick A. Masoudi
- Department of Medicine (Cardiology); University of Colorado Anschutz Medical Campus; Aurora Colorado
| | - Caroline S. Blaum
- Department of Medicine; New York University School of Medicine; New York New York
| | - John A. Dodson
- Department of Medicine; New York University School of Medicine; New York New York
| | - Ariel R. Green
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - Daniel Matlock
- Department of Medicine (General Internal Medicine); University of Colorado School of Medicine; Denver Colorado
| | - Jennifer Ouellet
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
| | - Michael W. Rich
- Department of Internal Medicine; Washington University School of Medicine; St Louis Missouri
| | - Nancy L. Schoenborn
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Mary E. Tinetti
- Department of Internal Medicine; Yale School of Medicine, Yale School of Public Health; New Haven Connecticut
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Affiliation(s)
- Mary E Tinetti
- Yale School of Medicine and Yale School of Public Health, New Haven, Connecticut (M.E.T., J.O.)
| | - Ariel R Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland (A.R.G., C.B.)
| | - Jennifer Ouellet
- Yale School of Medicine and Yale School of Public Health, New Haven, Connecticut (M.E.T., J.O.)
| | - Michael W Rich
- Washington University School of Medicine, St. Louis, Missouri (M.W.R.)
| | - Cynthia Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland (A.R.G., C.B.)
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Abstract
BACKGROUND Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. OBJECTIVE To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. PATIENTS AND METHODS We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. RESULTS Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. CONCLUSIONS Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA.
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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Green AR, Tung M, Segal JB. Older Adults' Perceptions of the Causes and Consequences of Healthcare Overuse: A Qualitative Study. J Gen Intern Med 2018; 33:892-897. [PMID: 29299815 PMCID: PMC5975132 DOI: 10.1007/s11606-017-4264-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/12/2017] [Accepted: 12/04/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Overuse of healthcare is pervasive in the United States, often exposing patients to harm with little likelihood of benefit. Older Americans are particularly vulnerable to overuse and impacted by it, yet it is unknown whether older patients perceive overuse as a consequential problem. OBJECTIVE To explore the experiences and perspectives of older adults with respect to healthcare overuse in order to develop a framework for understanding and reducing overuse in older adults. DESIGN Qualitative study using focus group methodology. PARTICIPANTS Five focus groups were held with people ≥65 years of age (N = 38) in four senior centers in Baltimore, Maryland, in 2016. APPROACH Transcripts were analyzed using qualitative content analysis to identify major themes. KEY RESULTS Of the 38 participants, 28 were women and 29 were African-American; 31 had at least a 12th grade education. While virtually all reported experience with what they perceived to have been healthcare overuse, some expressed concern that they had been denied appropriate care. They perceived overuse to have occurred when interventions were applied in the absence of symptoms (excluding cancer screening), did not improve symptoms, were discordant with their preferences, or were duplicative. Some defined overuse as interventions that were offered before less intensive options or too early in the course of disease. Suggested contributors to overuse were poor quality communication between patients and healthcare providers, and between different healthcare providers. Participants reported suffering from treatment effects, high costs, worry, and inconvenience from what they perceived to be overuse. They suggested that overuse may be reduced when the patient is involved in decision making and has a trusted primary care doctor. CONCLUSIONS The experience of older adults highlights potential sites of intervention to reduce healthcare overuse. Engaging patients in shared decision making and enhancing communication and knowledge transfer should be tested as interventions to reduce perceived overuse.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Monica Tung
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jodi B Segal
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Health Services and Outcomes Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Roxanis I, Colling R, Kartsonaki C, Green AR, Rakha EA. The significance of tumour microarchitectural features in breast cancer prognosis: a digital image analysis. Breast Cancer Res 2018; 20:11. [PMID: 29402299 PMCID: PMC5799893 DOI: 10.1186/s13058-018-0934-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/10/2018] [Indexed: 12/02/2022] Open
Abstract
Background As only a minor portion of the information present in histological sections is accessible by eye, recognition and quantification of complex patterns and relationships among constituents relies on digital image analysis. In this study, our working hypothesis was that, with the application of digital image analysis technology, visually unquantifiable breast cancer microarchitectural features can be rigorously assessed and tested as prognostic parameters for invasive breast carcinoma of no special type. Methods Digital image analysis was performed using public domain software (ImageJ) on tissue microarrays from a cohort of 696 patients, and validated with a commercial platform (Visiopharm). Quantified features included elements defining tumour microarchitecture, with emphasis on the extent of tumour-stroma interface. The differential prognostic impact of tumour nest microarchitecture in the four immunohistochemical surrogates for molecular classification was analysed. Prognostic parameters included axillary lymph node status, breast cancer-specific survival, and time to distant metastasis. Associations of each feature with prognostic parameters were assessed using logistic regression and Cox proportional models adjusting for age at diagnosis, grade, and tumour size. Results An arrangement in numerous small nests was associated with axillary lymph node involvement. The association was stronger in luminal tumours (odds ratio (OR) = 1.39, p = 0.003 for a 1-SD increase in nest number, OR = 0.75, p = 0.006 for mean nest area). Nest number was also associated with survival (hazard ratio (HR) = 1.15, p = 0.027), but total nest perimeter was the parameter most significantly associated with survival in luminal tumours (HR = 1.26, p = 0.005). In the relatively small cohort of triple-negative tumours, mean circularity showed association with time to distant metastasis (HR = 1.71, p = 0.027) and survival (HR = 1.8, p = 0.02). Conclusions We propose that tumour arrangement in few large nests indicates a decreased metastatic potential. By contrast, organisation in numerous small nests provides the tumour with increased metastatic potential to regional lymph nodes. An outstretched pattern in small nests bestows tumours with a tendency for decreased breast cancer-specific survival. Although further validation studies are required before the argument for routine quantification of microarchitectural features is established, our approach is consistent with the demand for cost-effective methods for triaging breast cancer patients that are more likely to benefit from chemotherapy.
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Affiliation(s)
- I Roxanis
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK. .,Present Address: Institute of Cancer Research, London and Royal Free London NHS Foundation Trust, London, UK.
| | - R Colling
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - C Kartsonaki
- Nuffield Department of Population Health, University of Oxford, Big Data Institute Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - A R Green
- Academic Pathology, Division of Cancer and Stem Cells, The University of Nottingham, Room 2-052-S Academic Unit of Oncology, Nottingham City Hospital, Nottingham, NG5 1PB, UK
| | - E A Rakha
- Department of Cellular Pathology, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
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Abdel-Fatah TMA, Agarwal D, Zafeiris D, Pongor L, Györffy B, Rueda OM, Moseley PM, Green AR, Liu DX, Pockley AG, Rees RC, Caldas C, Ellis IO, Ball GR, Chan SYT. Abstract P6-09-16: Identification of proliferation related derivers and their roles in precision medicine for breast cancers: A retrospective multidimensional comparative, integrated genomic, transcriptomic, and protein analysis. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p6-09-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Backgound and Aim: The best test to guide the choice of systemic therapy for breast cancer (BC) has not yet been identified. We did this study to identify factors that drive proliferation features in BC and assess their association with clinical outcomes after systemic therapy.
Methods: We applied an artificial neural network-based integrative data mining approach to three cohorts of patients with untreated lymph node (LN)-negative BC (Wang et al; n=286, Desmedt et al; n=198 and Schmidt et al; n=200). The results were validated in four cohorts of BC patients (the Nottingham discovery cohort (n=171), Uppsala cohort (n=249), The Cancer Genome Atlas-Breast Cancer project [TCGA-BRCA; n= 970] and Molecular Taxonomy of Breast Cancer International Consortium [METABRIC cohort; n=1980]. Genes that featured prominently in our interactome map of proliferation have been chosen to take them forward to investigate their clinicopathological relevance of their gene copy number aberrations (CNAs), mRNA transcript expression, and protein expression and their associations with breast cancer-specific survival (BCSS), distant relapse-free survival (DRFS) and pathological complete response (pCR) in ten international cohorts of BC (n>12000 patients).
Findings: ESR1, SPAG5, EGFR, BCL2, and FOXA1 were among the 39 common gene probes that were predictive across most proliferation features and datasets. In TCGA-BRCA cohort, SPAG5 gene mutation, gain/amplification and loss at the Ch17q11.2 locus were detected in 43 (4.4%), 177 (18.2%) and 180 (18.8%) of 970 patients, respectively and 65 (31%) of 479 ER-positive /HER-positive patients showed gain/amplification of SPAG5 gene. In multivariable analysis, high SPAG5 transcript and SPAG5 protein expression were associated with reduced BCSS compared with lower expression (METABRIC: HR 1·27, 95% CI 1·02–1·58, p=0·034; untreated LN-negative cohort: 2·34, 1·24–4·42, p=0·0090; and Nottingham-cohort: 1·73, 1·23–2·46, p=0·0020). In patients with ER-negative/HER2-negative or ER-positive/HER2-negative BC, high SPAG5 transcript expression was associated with an increased pCR compared with low SPAG5 transcript expression after receiving anthracycline neoadjuvant chemotherapy (AC-NeoACT) [(Multicentre phase 2 clinical trial cohort; n=136; OR 2·47, 95% CI 1·17–5·21, p=0.016) and (MD Anderson- taxane+AC-NeoACT cohort; n=287; OR 3·16, 95% CI 1·46–6·84, p=0.003); respectively]. In patients with ER-positive/HER2-negative BC who received taxane+AC-NeoACT followed by adjuvant tamoxifen (Adj-Tam) for 5 years (MD Anderson- taxane+AC-NeoACT cohort; n=287), high and low SPAG5 transcript expression had similar DRFS (HR 1·40, 95% CI 0.76–2·58, p=0.282). Whereas in ER-positive/HER2-negative BC patients who received only adj-Tam (n=298), high SPAG5 transcript expression was associated with reduced DRF at 5 years compared with lower expression (HR 1.98, 95% CI 1.19–3.27, p=0.008).
Interpretation: The transcript and protein products of SPAG5 are independent prognostic and predictive biomarkers that might have clinical utility as biomarkers for combination cytotoxic chemotherapy sensitivity in ER-positive/HER-negative BC.
Citation Format: Abdel-Fatah TMA, Agarwal D, Zafeiris D, Pongor L, Györffy B, Rueda OM, Moseley PM, Green AR, Liu D-X, Pockley AG, Rees RC, Caldas C, Ellis IO, Ball GR, Chan SYT. Identification of proliferation related derivers and their roles in precision medicine for breast cancers: A retrospective multidimensional comparative, integrated genomic, transcriptomic, and protein analysis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-16.
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Affiliation(s)
- TMA Abdel-Fatah
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - D Agarwal
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - D Zafeiris
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - L Pongor
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - B Györffy
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - OM Rueda
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - PM Moseley
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - AR Green
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - D-X Liu
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - AG Pockley
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - RC Rees
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - C Caldas
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - IO Ellis
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - GR Ball
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
| | - SYT Chan
- University of Nottingham Hospital NHS Trust, Nottingham, United Kingdom; John van Geest Cancer Research Centre, School of Science and Technology , Nottingham Trent University, Nottingham, United Kingdom; MTA TTK Lendület Cancer Biomarker Research Group, Budapest, Hungary; Cancer Research UK, Cambridge Research Institute, LiKa Shing Centre, Cambridge, United Kingdom; School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Liggins Institute, University of Auck, Auckland, New Zealand
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Affiliation(s)
- C N Harrison
- Department of Haematology, Guy's and St Thomas, Hospitals' NHS Foundation Trust, London, UK
| | - M F McMullin
- Department of Haematology, Queen's University, Belfast, UK
| | - A R Green
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - A J Mead
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Liam Hilson
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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Green AR, Segal J, Tian J, Oh E, Roth DL, Hilson L, Dodson JL, Boyd CM. Use of Bladder Antimuscarinics in Older Adults with Impaired Cognition. J Am Geriatr Soc 2016; 65:390-394. [PMID: 28185237 DOI: 10.1111/jgs.14498] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To examine the use of antimuscarinics for treating urinary incontinence (UI) in older adults with varying levels of cognition. DESIGN Cross-sectional. SETTING National Alzheimer's Coordinating Center from 2005 through 2015. PARTICIPANTS Community-dwelling men and women aged 65 and older (N = 24,106). MEASUREMENTS Clinicians and staff evaluated each participant's dementia status during annual in-person assessments. Participants or their informants reported all medications taken in the 2 weeks before each study visit. RESULTS Overall, 5.2% (95% confidence interval (CI) = 4.9-5.5%) of the cohort took a bladder antimuscarinic. Participants with impaired cognition were more likely to be taking an antimuscarinic than those with normal cognition. Rates of bladder antimuscarinic use were 4.0% (95% CI = 3.6-4.4%) for participants with normal cognition, 5.6% (95% CI = 4.9-6.3%) for those with mild cognitive impairment, and 6.0% (95% CI = 5.5-6.4%) for those with dementia (p < .001). Of 624 participants with dementia who took antimuscarinics, 16% (95% CI = 13-19%) were simultaneously taking other medicines with anticholinergic properties. CONCLUSION Use of bladder antimuscarinics was more common in older adults with impaired cognition than in those with normal cognition. This use is despite guidelines advising clinicians to avoid prescribing antimuscarinics in individuals with dementia because of their vulnerability to anticholinergic-induced adverse cognitive and functional effects. A substantial proportion of cognitively impaired individuals who took antimuscarinics were simultaneously taking other anticholinergic medications. These findings suggest a need to improve the treatment of UI in individuals with impaired cognition.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland
| | - Jodi Segal
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Esther Oh
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland.,Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David L Roth
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland
| | - Liam Hilson
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Haiwaii
| | - Jennifer L Dodson
- Department of Urology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Boullin DJ, Adams CBT, Mohan J, Green AR, Hunt TM, Boulay GHD, Rogers AT. Effects of Intracranial Dopamine Perfusion: Behavioural Arousal and Reversal of Cerebral Arterial Spasm following Surgery for Clipping of Ruptured Cerebral Aneurysms. Proc R Soc Med 2016. [DOI: 10.1177/00359157770700s211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D J Boullin
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - C B T Adams
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - J Mohan
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - A R Green
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - T M Hunt
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - G H Du Boulay
- Departments of Clinical Pharmacology and Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford O X2 6HE
| | - A T Rogers
- Nuffield Institute of Comparative Medicine, Zoological Society of London, Regents Park, London NW1
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Green AR, Jenkins A, Masoudi FA, Magid DJ, Kutner JS, Leff B, Matlock DD. Decision-Making Experiences of Patients with Implantable Cardioverter Defibrillators. Pacing Clin Electrophysiol 2016; 39:1061-1069. [PMID: 27566614 DOI: 10.1111/pace.12943] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/03/2016] [Accepted: 08/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND When patients are not adequately engaged in decision making, they may be at risk of decision regret. Our objective was to explore patients' perceptions of their decision-making experiences related to implantable cardioverter defibrillators (ICDs). METHODS Cross-sectional, mailed survey of 412 patients who received an ICD without cardiac resynchronization therapy for any indication between 2006 and 2009. Patients were asked about decision participation and decision regret. RESULTS A total of 295 patients with ICDs responded (72% response rate). Overall, 79% reported that they were as involved in the decision as they wanted. However, 28% reported that they were not told of the option of not getting an ICD and 37% did not remember being asked if they wanted an ICD. In total, 19% reported not wanting their ICD at the time of implantation. Those who did not want the ICD were younger (<65 years; 74% vs 43%, P < 0.001), had higher decision regret (31/100 vs 11/100, P < 0.001), and reported less participation in decision making (the doctor "totally" made the decision, 9% vs 3%; P < 0.001). CONCLUSIONS A considerable number of ICD recipients recalled not wanting their ICD at the time of implantation. While these findings may be prone to recall bias, they likely identify opportunities to improve ICD decision making.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Amy Jenkins
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
| | - David J Magid
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jean S Kutner
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado
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Agboola AOJ, Ebili HO, Iyawe VO, Banjo AAF, Salami BS, Rakha EA, Nolan C, Ellis IO, Green AR. Tumour cell membrane laminin expression is associated with basal-like phenotype and poor survival in Nigerian breast cancer. Malays J Pathol 2016; 38:83-92. [PMID: 27568664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Laminin is a glycoprotein with diverse functions in carcinogenesis including cell proliferation, invasion, metastases and epithelial-mesenchymal transition (EMT). In breast cancer (BC) laminin expression is speculated to be associated with unfavourable clinicopathological and molecular characteristics. We hypothesize that laminin expression would contributed to the aggressive nature of basal like and triple negative BC phenotype observed in Black women. METHODS The expression of laminin was determined in a well-characterised Nigerian cohort of 255 BC using tissue microarray and immunohistochemistry. Laminin expression was compared with clinical, pathological and survival characteristics. RESULTS Laminin was expressed in 146 (57.3%) cases and significantly correlated with younger age at diagnosis (p=0.005), premenopausal status (p=0.003), expression of EGFR (p=0.002), ID4 and MTA1, basal cytokeratin 5/6, p53, and triple negative tumours (all p<0.001). In addition, there was an inverse association of laminin expression with E-cadherin (p=0.03), ER and PgR (all p<0.001) and a trend with BRCA1 (p=0.05). Univariate survival analysis showed tumours positive for laminin had significantly poorer breast cancer specific survival (BCSS, p=0.009) and disease free interval (p=0.03), but not associated in Cox multivariate analysis. CONCLUSION This study demonstrates that laminin expression may have important roles in the aggressive nature observed in the basal-like and triple negative molecular subtype of Nigerian BC women.
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Affiliation(s)
- A O J Agboola
- Olabisi Onabanjo University, Faculty of Basic Medical Sciences, Department of Morbid Anatomy and Histopathology, Nigeria.
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Aleskandarany MA, Green AR, Ashankyty I, Elmouna A, Diez-Rodriguez M, Nolan CC, Ellis IO, Rakha EA. Impact of intratumoural heterogeneity on the assessment of Ki67 expression in breast cancer. Breast Cancer Res Treat 2016; 158:287-95. [PMID: 27380874 DOI: 10.1007/s10549-016-3893-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 12/27/2022]
Abstract
In breast cancer (BC), the prognostic value of Ki67 expression is well-documented. Intratumoural heterogeneity (ITH) of Ki67 expression is amongst the several technical issues behind the lag of its inclusion into BC prognostic work-up. The immunohistochemical (IHC) expression of anti-Ki67 antibody (MIB1 clone) was assessed in four full-face (FF) sections from different primary tumour blocks and their matched axillary nodal (LN) metastases in a series of 55 BC. Assessment was made using the highest expression hot spots (HS), lowest expression (LS), and overall/average expression scores (AS) in each section. Heterogeneity score (Hes), co-efficient of variation, and correlation co-efficient were used to assess the levels of Ki67 ITH. Ki67 HS, LS, and AS scores were highly variable within the same section and between different sections of the primary tumour, with maximal variation observed in the LS (P < 0.001). The least variability between the different slides was observed with HS scoring. Although the associations between Ki67 and clinicopathological and molecular variables were similar when using HS or AS, the best correlation between AS and HS was observed in tumours with high Ki67 expression only. Ki67 expression in LN deposits was less heterogeneous than in the primary tumours and was perfectly correlated with the HS Ki67 expression in the primary tumour sections (r = 0.98, P < 0.001). In conclusion, assessment of Ki67 expression using HS scoring method on a full-face BC tissue section can represent the primary tumour growth fraction that is likely to metastasise. The association between Ki67 expression pattern in the LN metastasis and the HS in the primary tumour may reflect the temporal heterogeneity through clonal expansion.
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Affiliation(s)
- M A Aleskandarany
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK.
- Faculty of Medicine, Menoufia University, Menoufia, Egypt.
| | - A R Green
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - I Ashankyty
- Molecular Diagnostics and Personalised Therapeutics Unit, University of Ha'il, Ha'il, Saudi Arabia
| | - A Elmouna
- Molecular Diagnostics and Personalised Therapeutics Unit, University of Ha'il, Ha'il, Saudi Arabia
| | - M Diez-Rodriguez
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - C C Nolan
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - I O Ellis
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - E A Rakha
- Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
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Evans AJ, Rakha EA, Pinder SE, Green AR, Paish C, Ellis IO. Basal phenotype: a powerful prognostic factor in small screen-detected invasive breast cancer with long-term follow-up. J Med Screen 2016; 14:210-4. [DOI: 10.1258/096914107782912004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A J Evans
- Radiology, Breast Institute, Nottingham City Hospital, Nottingham, UK
| | - E A Rakha
- Histopathology Department, Nottingham City Hospital, Nottingham, UK
| | - S E Pinder
- Histopathology Department, Addenbrookes Hospital Cambridge, Cambridge, UK
| | - A R Green
- Division of Pathology, School of Molecular Medical Sciences, University of Nottingham, Nottingham, UK
| | - C Paish
- Histopathology Department, Nottingham City Hospital, Nottingham, UK
| | - I O Ellis
- Histopathology Department, Nottingham City Hospital, Nottingham, UK
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Ahn JS, Li J, Chen E, Kent DG, Park HJ, Green AR. JAK2V617F mediates resistance to DNA damage-induced apoptosis by modulating FOXO3A localization and Bcl-xL deamidation. Oncogene 2016; 35:2235-46. [PMID: 26234675 DOI: 10.1038/onc.2015.285] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/28/2015] [Accepted: 06/22/2015] [Indexed: 12/21/2022]
Abstract
The JAK2V617F mutation is found in most patients with a myeloproliferative neoplasm (MPN). This gain-of-function mutation dysregulates cytokine signaling and is associated with increased accumulation of DNA damage, a process likely to drive disease evolution. JAK2V617F inhibits NHE-1 upregulation in response to DNA damage and consequently represses Bcl-xL deamidation and apoptosis, thus giving rise to inappropriate cell survival. However, the mechanism whereby NHE-1 expression is inhibited by JAK2V617F is unknown. In this study, we demonstrate that the accumulation of reactive oxygen species (ROS) in cells expressing JAK2V617F compromises the NHE-1/Bcl-xL deamidation pathway by repressing NHE-1 upregulation in response to DNA damage. In JAK2V617F-positive cells, increased ROS levels results from aberrant PI3K signaling, which decreases nuclear localization of FOXO3A and decreases catalase expression. Furthermore, when compared with autologous control erythroblasts, clonally derived JAK2V617F-positive erythroblasts from MPN patients displayed increased ROS levels and reduced nuclear FOXO3A. However, in hematopoietic stem cells (HSCs), FOXO3A is largely localized within the nuclei despite the presence of JAK2V617F mutation, suggesting that JAK2-FOXO signaling has a different effect on progenitors compared with stem cells. Inactivation of FOXO proteins and elevation of intracellular ROS are characteristics common to many cancers, and hence these findings are likely to be of relevance beyond the MPN field.
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Affiliation(s)
- J S Ahn
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - J Li
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - E Chen
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - D G Kent
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - H J Park
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - A R Green
- Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
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Green AR, Leff B, Wang Y, Spatz ES, Masoudi FA, Peterson PN, Daugherty SL, Matlock DD. Geriatric Conditions in Patients Undergoing Defibrillator Implantation for Prevention of Sudden Cardiac Death: Prevalence and Impact on Mortality. Circ Cardiovasc Qual Outcomes 2015; 9:23-30. [PMID: 26715650 DOI: 10.1161/circoutcomes.115.002053] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/13/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Geriatric conditions may influence outcomes among patients receiving implantable cardioverter-defibrillators (ICDs). We sought to determine the prevalence of frailty and dementia among older adults receiving primary prevention ICDs and to determine the impact of multimorbidity on mortality within 1 year of ICD implantation. METHODS AND RESULTS The cohort included 83 792 Medicare patients from the National Cardiovascular Data Registry ICD Registry who underwent first primary prevention ICD implantation between 2006 and 2009. These data were merged with Medicare analytic files to determine the prevalence of frailty, dementia, and other conditions before ICD implantation, as well as 1-year mortality. A validated claim-based algorithm was used to identify frail patients. Mutually exclusive patterns of chronic conditions were examined. The association of each pattern with 1-year mortality was assessed using logistic regression models adjusted for selected patient characteristics. Approximately 1 in 10 Medicare patients with heart failure receiving a primary prevention ICD had frailty (10%) or dementia (1%). One-year mortality was 22% for patients with frailty, 27% for patients with dementia, and 12% in the overall cohort. Several multimorbidity patterns were associated with high 1-year mortality rates: dementia with frailty (29%), frailty with chronic obstructive pulmonary disease (25%), and frailty with diabetes mellitus (23%). These patterns were present in 8% of the cohort. CONCLUSIONS More than 10% of Medicare beneficiaries with heart failure receiving primary prevention ICDs have frailty or dementia. These patients had significantly higher 1-year mortality than those with other common chronic conditions. Frailty and dementia should be considered in clinical decision-making and guideline development.
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Affiliation(s)
- Ariel R Green
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO.
| | - Bruce Leff
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Yongfei Wang
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Erica S Spatz
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Frederick A Masoudi
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Pamela N Peterson
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Stacie L Daugherty
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
| | - Daniel D Matlock
- From the Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine (A.R.G., B.L.); Department of Health Policy and Management, Bloomberg School of Public Health (B.L), Johns Hopkins University Baltimore, MD; Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, MD (B.L.); Section of Cardiovascular Medicine (Y.W., E.S.S.), Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation (Y.W., E.S.S.), Yale/Yale-New Haven Hospital Systems, New Haven, CT; Division of Cardiology, Department of Medicine (F.A.M., P.N.P., S.L.D.) and Division of Geriatrics, Department of Medicine (D.D.M.), University of Colorado, Anschutz Medical Campus, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium (F.A.M., S.L.D., D.D.M., P.N.P.), Denver, CO; Division of Cardiology, Department of Medicine (P.N.P.), Denver Health Medical Center, Denver, CO
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Green AR, Boyd CM, Rickard J, Gomon R, Leff B. Attitudes of older adults with serious competing health risks toward their implantable cardioverter-defibrillators: a pilot study. BMC Geriatr 2015; 15:173. [PMID: 26700296 PMCID: PMC4690308 DOI: 10.1186/s12877-015-0173-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/16/2015] [Indexed: 11/23/2022] Open
Abstract
Background In elderly heart failure patients, the survival benefit of implantable cardioverter-defibrillators (ICDs) may be attenuated due to competing health risks, and the risk of adverse outcomes magnified. Our objective was to examine older adults’ attitudes towards ICD implantation in the context of competing health risks, exploring the determinants of ICD decision-making among a group of patients who had faced the decision in the past. Methods Telephone survey with a qualitative component. Patients were age ≥70 with single- or dual-chamber ICDs from a single academic cardiac device clinic. Health status was assessed with the Vulnerable Elders Survey (VES-13). Responses to open-ended questions were transcribed verbatim; an “editing analysis” approach was used to extract themes. Results Forty-four ICD recipients participated (mean age 77.5 years). Nineteen participants (43 %) had VES-13 scores ≥3, indicating a 50 % likelihood of death or functional decline within 2 years. Twenty-one participants (48 %) had received prior ICD shocks. Forty participants (91 %) said they would “definitely” choose to get an ICD again in their current health. By and large, patients revealed a strong desire to extend life, expressed complete confidence in the lifesaving capabilities of their ICDs, and did not describe consideration of competing health risks. Conclusions In this pilot telephone survey with a qualitative component, nearly all older adults with ICDs would still choose to get an ICD despite high short-term risk of death or health deterioration. These findings suggest the need to partner more effectively with patients and families to decide how best to use medical technologies, particularly for older adults with competing risks.
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Affiliation(s)
- Ariel R Green
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA.
| | - John Rickard
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Robert Gomon
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 301 building, Baltimore, MD, 21224, USA.
| | - Bruce Leff
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, 7th floor, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA. .,Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, USA.
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47
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Kramer DB, Matlock DD, Buxton AE, Goldstein NE, Goodwin C, Green AR, Kirkpatrick JN, Knoepke C, Lampert R, Mueller PS, Reynolds MR, Spertus JA, Stevenson LW, Mitchell SL. Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium. Circ Cardiovasc Qual Outcomes 2015; 8:437-46. [PMID: 26038525 DOI: 10.1161/circoutcomes.114.001660] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.).
| | - Daniel D Matlock
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Alfred E Buxton
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Nathan E Goldstein
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Carol Goodwin
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Ariel R Green
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - James N Kirkpatrick
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Christopher Knoepke
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Rachel Lampert
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Paul S Mueller
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Matthew R Reynolds
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - John A Spertus
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Lynne W Stevenson
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Susan L Mitchell
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
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48
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Stebbing J, Zhang H, Xu Y, Lit LC, Green AR, Grothey A, Lombardo Y, Periyasamy M, Blighe K, Zhang W, Shaw JA, Ellis IO, Lenz HJ, Giamas G. KSR1 regulates BRCA1 degradation and inhibits breast cancer growth. Oncogene 2015; 34:2103-14. [PMID: 24909178 DOI: 10.1038/onc.2014.129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/02/2014] [Accepted: 04/12/2014] [Indexed: 12/16/2022]
Abstract
Kinase suppressor of Ras-1 (KSR1) facilitates signal transduction in Ras-dependent cancers, including pancreatic and lung carcinomas but its role in breast cancer has not been well studied. Here, we demonstrate for the first time it functions as a tumor suppressor in breast cancer in contrast to data in other tumors. Breast cancer patients (n>1000) with high KSR1 showed better disease-free and overall survival, results also supported by Oncomine analyses, microarray data (n=2878) and genomic data from paired tumor and cell-free DNA samples revealing loss of heterozygosity. KSR1 expression is associated with high breast cancer 1, early onset (BRCA1), high BRCA1-associated ring domain 1 (BARD1) and checkpoint kinase 1 (Chk1) levels. Phospho-profiling of major components of the canonical Ras-RAF-mitogen-activated protein kinases pathway showed no significant changes after KSR1 overexpression or silencing. Moreover, KSR1 stably transfected cells formed fewer and smaller size colonies compared to the parental ones, while in vivo mouse model also demonstrated that the growth of xenograft tumors overexpressing KSR1 was inhibited. The tumor suppressive action of KSR1 is BRCA1 dependent shown by 3D-matrigel and soft agar assays. KSR1 stabilizes BRCA1 protein levels by reducing BRCA1 ubiquitination through increasing BARD1 abundance. These data link these proteins in a continuum with clinical relevance and position KSR1 in the major oncoprotein pathways in breast tumorigenesis.
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Affiliation(s)
- J Stebbing
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - H Zhang
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - Y Xu
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - L C Lit
- 1] Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK [2] Faculty of Medicine, Department of Physiology, University of Malaya, Kuala, Lumpur, Malaysia
| | - A R Green
- Department of Cellular Pathology, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - A Grothey
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - Y Lombardo
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - M Periyasamy
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
| | - K Blighe
- Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - W Zhang
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Centre, Keck School of Medicine, Los Angeles, CA, USA
| | - J A Shaw
- Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
| | - I O Ellis
- Faculty of Medicine, Department of Physiology, University of Malaya, Kuala, Lumpur, Malaysia
| | - H J Lenz
- Division of Medical Oncology, University of Southern California, Norris Comprehensive Cancer Centre, Keck School of Medicine, Los Angeles, CA, USA
| | - G Giamas
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Imperial College Centre for Translational and Experimental Medicine, Hammersmith Hospital Campus, London, UK
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49
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Green AR. Capsule commentary on Jones et al., the future as a series of transitions: qualitative study of heart failure patients and their informal caregivers. J Gen Intern Med 2015; 30:238. [PMID: 25472510 PMCID: PMC4314476 DOI: 10.1007/s11606-014-3134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, 21224, USA,
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50
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Green AR, King MV, Shortall SE, Fone KCF. The preclinical pharmacology of mephedrone; not just MDMA by another name. Br J Pharmacol 2014; 171:2251-68. [PMID: 24654568 DOI: 10.1111/bph.12628] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 12/05/2013] [Accepted: 12/11/2013] [Indexed: 01/15/2023] Open
Abstract
The substituted β-keto amphetamine mephedrone (4-methylmethcathinone) was banned in the UK in April 2010 but continues to be used recreationally in the UK and elsewhere. Users have compared its psychoactive effects to those of 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy'). This review critically examines the preclinical data on mephedrone that have appeared over the last 2-3 years and, where relevant, compares the pharmacological effects of mephedrone in experimental animals with those obtained following MDMA administration. Both mephedrone and MDMA enhance locomotor activity and change rectal temperature in rodents. However, both of these responses are of short duration following mephedrone compared with MDMA probably because mephedrone has a short plasma half-life and rapid metabolism. Mephedrone appears to have no pharmacologically active metabolites, unlike MDMA. There is also little evidence that mephedrone induces a neurotoxic decrease in monoamine concentration in rat or mouse brain, again in contrast to MDMA. Mephedrone and MDMA both induce release of dopamine and 5-HT in the brain as shown by in vivo and in vitro studies. The effect on 5-HT release in vivo is more marked with mephedrone even though both drugs have similar affinity for the dopamine and 5-HT transporters in vitro. The profile of action of mephedrone on monoamine receptors and transporters suggests it could have a high abuse liability and several studies have found that mephedrone supports self-administration at a higher rate than MDMA. Overall, current data suggest that mephedrone not only differs from MDMA in its pharmacological profile, behavioural and neurotoxic effects, but also differs from other cathinones.
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Affiliation(s)
- A R Green
- School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
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