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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Bancks MP, Mathioudakis NN, Maruthur NM. A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications. J Gen Intern Med 2024; 39:992-1001. [PMID: 37940754 DOI: 10.1007/s11606-023-08506-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN National physician survey. PARTICIPANTS US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rabia Jalalzai
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P Bancks
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Hurley VB, Giletta E, Yang Y, Mollenkopf NL, Jalalzai R, Schwartz JL, Chen AR, Pitts SI. Understanding the Information Needs of Pharmacy Staff Using CancelRx: A Qualitative Study of the Use of Prescription E-cancellation. Explor Res Clin Soc Pharm 2024; 13:100398. [PMID: 38204887 PMCID: PMC10776446 DOI: 10.1016/j.rcsop.2023.100398] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 01/12/2024] Open
Abstract
Background Although electronic prescription cancellation such as via CancelRx can facilitate critical communication between prescribers and pharmacy staff about discontinued medications, there is little work that explores whether CancelRx meets the needs of pharmacy staff users. Objective This study leverages qualitative interviews with pharmacy staff to address the following question: When medication changes are made by a prescriber using CancelRx, what information is needed by pharmacy staff to make correct and effective decisions in their roles in medication management? Methods We conducted an inductive thematic analysis of interviews with 11 pharmacy staff members (pharmacists and pharmacy technicians) across three outpatient community pharmacy sites within an academic health care system. Results Three information needs themes were consistently identified by both pharmacists and pharmacy technicians: prescriber intent when initiating the CancelRx, clinical rationale for the medication change, and intended medication regimen. Notably, both pharmacists and pharmacy technicians often reported seeking multiple information needs not fully addressed by CancelRx in the electronic health record (EHR) to achieve the shared goals of correct dispensing of medications and supporting patient self-management. Conclusions Our qualitative analysis reveals that outpatient community pharmacy staff in an academic health care system often seek additional information from the (EHR) following medication changes communicated by CancelRx to meet their information needs. Ideally, the prescriber would provide sufficient information through CancelRx to automatically identify all discontinued prescriptions. These limitations highlight the need for design features that support routine communication of needed information at the time of a medication change, such as structured data elements.
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Affiliation(s)
- Vanessa B. Hurley
- Health Management and Policy, School of Health, Georgetown University, St. Mary's Hall 231, 3700 Reservoir Rd NW, Washington, DC 20057, United States
| | - Elaine Giletta
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
| | - Yushi Yang
- Johns Hopkins Medicine, 1800 Orlean St., Carnegie 638, Baltimore, MD 21205, United States
| | - Nicole L. Mollenkopf
- Johns Hopkins University School of Nursing, 525 North Wolfe St. Room 414, Baltimore, MD 21205, United States
| | - Rabia Jalalzai
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
| | - Jessica L. Schwartz
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 2024 E. Monument St, Ste 2-604D, Baltimore, MD 21205, United States
| | - Allen R. Chen
- Department of Oncology and Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD 21287, United States
| | - Samantha I. Pitts
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument St., Room 8020, Baltimore, MD 21210, United States
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Glass N, Jalalzai R, Spiegel P, Rubenstein L. Correction to: The crisis of maternal and child health in Afghanistan. Confl Health 2023; 17:32. [PMID: 37349794 DOI: 10.1186/s13031-023-00529-6] [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] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Affiliation(s)
- Nancy Glass
- Johns Hopkins School of Nursing, Baltimore, MD, USA.
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Johns Hopkins Center for Humanitarian Health, Baltimore, MD, USA.
| | | | - Paul Spiegel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Center for Humanitarian Health, Baltimore, MD, USA
| | - Leonard Rubenstein
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Center for Humanitarian Health, Baltimore, MD, USA
- Center for Human Rights and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Golden SH, Mathioudakis NN, Maruthur NM. A National Physician Survey of Deintensifying Diabetes Medications for Older Adults With Type 2 Diabetes. Diabetes Care 2023; 46:1164-1168. [PMID: 36800554 PMCID: PMC10234750 DOI: 10.2337/dc22-2146] [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: 11/04/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To determine physicians' approach to deintensifying (reducing/stopping) or switching hypoglycemia-causing medications for older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS In this national survey, U.S. physicians in general medicine, geriatrics, or endocrinology reported changes they would make to hypoglycemia-causing medications for older adults in three scenarios: good health, HbA1c of 6.3%; complex health, HbA1c of 7.3%; and poor health, HbA1c of 7.7%. RESULTS There were 445 eligible respondents (response rate 37.5%). In patient scenarios, 48%, 4%, and 20% of physicians deintensified hypoglycemia-causing medications for patients with good, complex, and poor health, respectively. Overall, 17% of physicians switched medications without significant differences by patient health. One-half of physicians selected HbA1c targets below guideline recommendations for older adults with complex or poor health. CONCLUSIONS Most U.S. physicians would not deintensify or switch hypoglycemia-causing medications within guideline-recommended HbA1c targets. Physician preference for lower HbA1c targets than guidelines needs to be addressed to optimize deintensification decisions.
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Affiliation(s)
- Scott J. Pilla
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Rabia Jalalzai
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Nancy L. Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia M. Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M. Maruthur
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
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Miller MJ, DiNucci AJ, Jalalzai R, Rabinovich N, Roblin DW. Time-series analysis of recent antihyperglycemic medication prescribing trends for a diverse sample of Medicare enrollees with type 2 diabetes mellitus in an integrated health system. Am J Health Syst Pharm 2022; 79:950-959. [PMID: 35176753 DOI: 10.1093/ajhp/zxac056] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Despite high type 2 diabetes mellitus (T2DM) prevalence in Medicare enrollees, newer therapeutic options, and revised treatment guidelines, little is known about US antihyperglycemic prescribing trends after 2015. This research describes recent monthly antihyperglycemic prescribing trends in a large, diverse population of Medicare enrollees from the US Mid-Atlantic region. METHODS Encounter data (July 2018-July 2020) for Medicare enrollees 65 years of age or older with T2DM were extracted from electronic health records of a large integrated health system. Descriptive time-series regression models were estimated to describe monthly prescribing rates (ie, prescription orders per 100 eligible plan members with T2DM) overall and by medication subgroups for all-eligible and continuously-eligible samples. Trends in monthly prescription orders per 100 eligible plan members with T2DM were reported. RESULTS The monthly all-eligible member sample (n > 22,000) exhibited an overall positive baseline monthly prescribing rate of 23.88 T2DM medication orders per 100 members with T2DM and a significant positive monthly prescribing rate trend (ie, change) of 0.12 T2DM medication orders per 100 members with T2DM (P < 0.05). Subgroup T2DM medication order rates per 100 members with T2DM at baseline were 16.28 for first generation medications, 3.87 for human insulins, 3.04 for insulin analogs, 0.58 for second-generation medications, and 0.11 for combination medications. Human insulins, insulin analogs, and second-generation medications had positive monthly trends (P < 0.05). Among second-generation Medications, sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists had positive monthly trends (P < 0.05). Continuously eligible members with T2DM (n = 19,185) had no significant overall monthly prescribing trend; however, human insulins, insulin analogs, and second-generation medications and the SGLT-2 inhibitor class had positive monthly prescribing trends (P < 0.05). CONCLUSION In a diverse Medicare sample, this study observed increasing monthly trends for second-generation medications, human insulins, and insulin analogs consistent with emerging evidence. Among second-generation medications, SGLT-2 inhibitors became the most commonly prescribed over time.
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Affiliation(s)
- Michael J Miller
- Mid-Atlantic Permanente Research Institute (MAPRI), Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Anna J DiNucci
- Mid-Atlantic Permanente Research Institute (MAPRI), Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Rabia Jalalzai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nonna Rabinovich
- Mid-Atlantic Permanente Research Institute (MAPRI), Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute (MAPRI), Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
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