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Masnoon N, George C, Lo S, Tan E, Bordia A, Hilmer S. The outcomes of considering goals of care in medication reviews for older adults: a systematic review. Expert Rev Clin Pharmacol 2024; 17:33-56. [PMID: 38145414 DOI: 10.1080/17512433.2023.2286321] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 11/17/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults. METHODS A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English. RESULTS Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective. CONCLUSIONS There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.
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Affiliation(s)
- Nashwa Masnoon
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Cristen George
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarita Lo
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Edwin Tan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Aagam Bordia
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia
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Page AT, Potter K, Naganathan V, Hilmer S, McLachlan AJ, Lindley RI, Coman T, Mangin D, Etherton-Beer C. Polypharmacy and medicine regimens in older adults in residential aged care. Arch Gerontol Geriatr 2023; 105:104849. [PMID: 36399891 DOI: 10.1016/j.archger.2022.104849] [Citation(s) in RCA: 2] [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: 10/14/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe medicines regimens used by older people living in residential aged care facilities (RACFs). MATERIALS AND METHODS This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively. RESULTS Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade. CONCLUSION(S) Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.
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Affiliation(s)
- Amy Theresa Page
- Centre for Optimisation of Medicines, School of Allied Health, The University of Western Australia, Crawley, Western Australia, Australia; WA Centre for Health and Ageing, The University of Western Australia, Perth, Western Australia, Australia.
| | | | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Andrew J McLachlan
- ydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Richard I Lindley
- University of Sydney, Sydney, Australia and the George Institute for Global Health, Sydney, Australia
| | - Tracy Coman
- Menzies Health Institute Queensland, Griffith University, University Drive Meadowbrook, Brisbane, Queensland, Australia
| | | | - Christopher Etherton-Beer
- WA Centre for Health and Ageing, The University of Western Australia, Perth, Western Australia, Australia; Department of Geriatric Medicine, Royal Perth Hospital, Perth, Australia
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Masnoon N, Lo S, Hilmer S. A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records. Br J Clin Pharmacol 2023; 89:687-698. [PMID: 36038522 PMCID: PMC10953400 DOI: 10.1111/bcp.15517] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The drug burden index (DBI) measures a person's total exposure to anticholinergic and sedative medications, which are commonly associated with harm. Through incorporating the DBI in electronic medical records (eMR) and implementing a DBI stewardship program, we aimed to determine (i) uptake of the steward's recommendations to deprescribe anticholinergic and/or sedative drugs by the medical team and (ii) whether accepted recommendations were actioned in hospital or recommended for follow-up by the General Practitioner post-discharge. METHODS A single-arm, non-randomised feasibility study was performed at an Australian tertiary referral metropolitan hospital. The stewardship pharmacist reviewed eMRs of patients aged ≥75 years with DBI scores > 0, during admission. The steward identified and discussed potential opportunities to deprescribe anticholinergic and/or sedative medications with the medical registrars. RESULTS Amongst 256 patients reviewed, the steward made 170 recommendations for 117 patients. Registrars agreed with 141 recommendations (82.9%) for 95 patients (81.2%), and actioned 115 deprescribing recommendations for 80 patients, most commonly for antidepressants and opioids. The 115 actioned recommendations resulted in 125 changes, with 44 changes to the inpatient drug chart and 81 additional changes recommended post-discharge in the discharge summary. CONCLUSION Opportunities exist for deprescribing anticholinergic and sedative medications in older inpatients and a DBI stewardship program may help implement these. It is important to capture different outcomes of deprescribing interventions, including in-hospital medication changes, recommendations in the Discharge Summary, sustainability of deprescribing and clinical outcomes.
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Affiliation(s)
- Nashwa Masnoon
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarita Lo
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - Sarah Hilmer
- Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
- Departments of Clinical Pharmacology and Aged CareRoyal North Shore HospitalSydneyNSWAustralia
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Baysari MT, Van Dort BA, Stanceski K, Hargreaves A, Zheng WY, Moran M, Day R, Li L, Westbrook J, Hilmer S. Is evidence of effectiveness a driver for clinical decision support selection? A qualitative descriptive study of senior hospital staff. Int J Qual Health Care 2023; 35:7008757. [PMID: 36715081 PMCID: PMC9940455 DOI: 10.1093/intqhc/mzad004] [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: 04/25/2022] [Revised: 11/20/2022] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Limited research has focused on understanding if and how evidence of health information technology (HIT) effectiveness drives the selection and implementation of technologies in practice. This study aimed to explore the views of senior hospital staff on the role evidence plays in the selection and implementation of HIT, with a particular focus on clinical decision support (CDS) alerts in electronic medication management systems. A qualitative descriptive design was used. Twenty senior hospital staff from six Australian hospitals in New South Wales and Queensland took part in a semistructured interview. Interviews were audio-recorded and transcribed, and a general inductive content analysis approach was used to identify themes. Participants acknowledged the importance of an evidence base, but reported that selection of CDS alerts, and HIT more broadly, was rarely underpinned by evidence that technologies improve patient care. Instead, investments in technologies were guided by the expectation that benefits will be achieved, bolstered by vendor assurances, and a perception that implementation of HIT is unavoidable. Postponing implementation of a technology until an evidence base is available was not always feasible. Although some technologies were seen as not requiring an evidence base, stakeholders viewed evidence as extremely valuable for informing decisions about selection of CDS alerts. In the absence of evidence, evaluation or monitoring of technologies postimplementation is critical, particularly to identify new errors or risks associated with HIT implementation and use. Increased transparency from vendors, with technology evaluation outcomes made directly available to healthcare organizations, may result in less reliance on logic, intuition, and vendor assertions and more evidence-based selection of HIT.
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Affiliation(s)
- Melissa T Baysari
- *Corresponding author. Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Room 132 RC Mills Building, Camperdown, NSW 2006, Australia. E-mail:
| | - Bethany A Van Dort
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Kristian Stanceski
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Andrew Hargreaves
- Integrated Care, eHealth NSW, Level 15, Zenith Tower B, 821 Pacific Highway, Chatswood, NSW 2067, Australia
| | - Wu Yi Zheng
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia,Directorate of Strategy and Operations, Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia
| | - Maria Moran
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Richard Day
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Darlinghurst, NSW 2010, Australia,The Clinical School, St Vincent’s Clinical School, UNSW Medicine, UNSW Sydney, NSW 2052, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road NSW 2109, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road NSW 2109, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney and Royal North Shore Hospital, NSW 2065, Australia,Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, NSW 2065, Australia
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Thillainadesan J, Aitken S, Monaro S, Cullen J, Kerdic R, Hilmer S, Naganathan V. GERIATRICIAN CO-MANAGEMENT AND EDUCATION OF JUNIOR DOCTORS IMPROVE THE CARE OF HOSPITALIZED OLDER SURGICAL PATIENTS. Innov Aging 2022. [DOI: 10.1093/geroni/igac059.333] [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: 12/24/2022] Open
Abstract
Abstract
We evaluated changes in processes of care after the introduction of a novel model of care for older vascular surgery inpatients. This model, called Geriatrics Co-management of older vascular surgery patients (GeriCO-V) embedded a geriatrician into the vascular surgery team who provided proactive geriatrics assessment of patients and education for junior surgical doctors. A pre-post study of the GeriCO-V model comparing prospectively recruited pre-intervention (n=150) and post-intervention (n=152) cohorts of consecutively admitted vascular surgery patients aged ≥65 years at an acute care academic hospital. Education of junior surgical doctors was embedded in the new model of care and included role modelling, provision of delirium and frailty screening lanyards and mobile Apps for ‘just-in-time’ learning, and a Wiki page of tips on assessing older patients. We measured processes of care by review of medical charts. After implementing the novel geriatrician and education embedded model of care, there was a significant increase in several processes of care by the junior surgical doctor: screening for cognition (8% vs 76%, p<.001) and delirium (2% vs 69%, p<.001), documentation of functional history (34% vs 76%, p<.001), medications (53% vs 74%, p<.001) and treatment preferences (5% vs 46%, p<.001) and prescribing of pharmacological venous thromboprophylaxis (93% vs 99%, p=.03) and co-prescription of laxative with opioid (60% vs 81%, p=.002). A collaborative model of care that embeds proactive geriatrician care and education of junior surgical doctors improves the quality of care for older vascular surgical patients.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine and Centre for Education and Research on Ageing (CERA), Concord Hospital , Concord, New South Wales , Australia
| | - Sarah Aitken
- Concord Hospital , Concord, New South Wales , Australia
| | - Sue Monaro
- Concord Hospital , Concord, New South Wales , Australia
| | - John Cullen
- Concord Hospital , Concord, New South Wales , Australia
| | | | - Sarah Hilmer
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Baysari MT, Dort BAV, Zheng WY, Li L, Hilmer S, Westbrook J, Day R. Prescribers’ reported acceptance and use of drug-drug interaction alerts: An Australian survey. Health Informatics J 2022; 28:14604582221100678. [DOI: 10.1177/14604582221100678] [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: 11/17/2022]
Abstract
Drug-drug interaction (DDI) alerts are frequently included in electronic medical record (eMR) systems to provide users with relevant information and guidance at the point of care. In this study, we aimed to examine views of DDI alerts among prescribers, including junior doctors, registrars and senior doctors, across Australia. A validated survey for assessing prescribers’ reported acceptance and use of DDI alerts was distributed among researcher networks and in newsletters. Fifty useable responses were received, more than half ( n = 28) from senior doctors. Prescribers at all levels expected DDI alerts to improve performance but junior doctors reported that this was at a high cost, with respect to time and effort. Senior doctors and registrars reported rarely reading alerts and rarely changing prescribing decisions based on alerts. Respondents identified a number of problems with current alerts including limited relevance, repetition, and poor design, highlighting some clear areas for alert improvement.
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Affiliation(s)
- Melissa T Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, NSW, Australia
| | - Bethany A Van Dort
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, NSW, Australia
| | - Wu Yi Zheng
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, NSW, Australia
- Black Dog Institute, NSW Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Richard Day
- Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, NSW, Australia
- St Vincent’s Clinical School, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Ngui K, Lam P, Materne M, Hilmer S. Patient-reported Experience Measures in Deprescribing for Hospitalised Older Patients: A Prospective, Multicentre, Observational Study. Intern Med J 2022. [PMID: 35112777 DOI: 10.1111/imj.15707] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/18/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hospitalisation provides an opportunity for medication review and deprescribing. Patient-reported experience measures (PREM) for deprescribing in older patients in-hospital are not well-described. AIM To pilot test and describe PREM for deprescribing in older patients, compare PREM by patient characteristics, and investigate patients' awareness of medication changes on hospital discharge. METHODS This prospective, multicentre, observational cohort study at two tertiary hospitals in Sydney, Australia, evaluated the PREM questionnaire developed by the NSW Therapeutic Advisory Group. It was completed by patients (or their next of kin) recruited from acute geriatric medicine and orthogeriatric services. Association with nine patient characteristics was analysed using the chi-square test and multivariable regression. Awareness of medication changes and test-retest reliability were analysed using descriptive statistics. RESULTS Overall, 201 participants completed the questionnaire, with 170 eligible for analysis; 34/170 (20%) were aware of reduction or cessation of their usual medications on discharge and reported involvement in decision making and receiving enough information to reduce or stop one or more of their usual medications (positive PREM). Independent predictors of positive PREM included respondent (next of kin), hospital (Hospital 1), language (English), and specialty (acute geriatric medicine). Overall, 92 of 155 (59.4%) patients with medication changes were aware of those changes on hospital discharge. CONCLUSIONS These PREMs are a feasible tool to examine older patients' experiences of deprescribing in-hospital and may be applied to evaluate interventions to improve awareness, shared decision making, and provision of information when deprescribing for older patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Keat Ngui
- Department of General & Acute Medicine, Liverpool Hospital, Liverpool NSW 2170, Australia. Faculty of Health and Medicine, University of Newcastle
| | - Patrick Lam
- Orthopaedic Research Institute, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, Australia, Level 2, 4-10 South Street, Kogarah, Sydney, New South Wales, 2217, Australia
| | | | - Sarah Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute, Royal North Shore Hospital and Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, 2065, Australia
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Affiliation(s)
- Sarah Hilmer
- Geriatric Pharmacology, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ruth E Hubbard
- Geriatric Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia
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Thillainadesan J, Hilmer S, Mudge A, Aitken S, Naganathan V. Understanding the Role and Value of Process Quality Indicators in Hospitalized Older Surgical Patients. Innov Aging 2021. [PMCID: PMC8680742 DOI: 10.1093/geroni/igab046.2235] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Despite the development of geriatrics surgery process quality indicators (QIs), few studies have reported on these QIs in routine surgical practice. Even less is known about the links between these QIs and clinical outcomes, and patient characteristics. We aimed to measure geriatrics surgery process QIs, and investigate the association between process QIs and outcomes, and QIs and patient characteristics, in hospitalized older vascular surgery patients. Methods This was a prospective cohort study of 150 consecutive patients aged ≥ 65 years admitted to a tertiary vascular surgery unit. Occurrence of geriatrics surgery process QIs as part of routine vascular surgery care was measured. Associations between QIs and high-risk patient characteristics, and QIs and clinical outcomes were assessed using clustered heatmaps. Results QI occurrence rate varied substantially from 2% to 93%. Some QIs, such as cognition and delirium screening, documented treatment preferences, and geriatrician consultation were infrequent and clustered with high-risk patients. There were two major process-outcome clusters: (a) multidisciplinary consultations, communication and screening-based process QIs with multiple adverse outcomes, and (b) documentation and prescribing-related QIs with fewer adverse outcomes. Conclusions Clustering patterns of process QIs with clinical outcomes are complex, and there is a differential occurrence of QIs within older vascular surgery patients, suggesting process QIs alone may be unreliable targets for quality improvement. Prospective intervention studies are needed to understand the causal pathways between process QIs and outcomes to help prioritize care processes that are most clearly linked to improved outcomes.
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Affiliation(s)
| | - Sarah Hilmer
- The University of Sydney, St Leonards, New South Wales, Australia
| | - Alison Mudge
- Royal Brisbane and Women’s Hospital, Royal Brisbane and Women’s Hospital, Queensland, Australia
| | - Sarah Aitken
- University of Sydney, Concord, New South Wales, Australia
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Thillainadesan J, Aitken S, Monaro S, Cullen J, Kerdic R, Hilmer S, Naganathan V. Geriatric Comanagement Reduces Hospital-Acquired Geriatric Syndromes in Older Vascular Surgery Inpatients. Innov Aging 2021. [PMCID: PMC8680491 DOI: 10.1093/geroni/igab046.1261] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aims Based on our meta-analysis, surveys and qualitative studies of geriatricians in Australia and New Zealand, we designed and implemented a novel inpatient model to co-manage older vascular surgical inpatients at a tertiary academic hospital in Sydney. This model, called Geriatrics co-management of older vascular surgery patients (Gerico-V), embedded a geriatrician into the vascular surgery unit who introduced a range of interventions targeting older people. Here we evaluated this model of care. Methods We undertook a prospective before-and-after study of consecutive patients aged ≥65 years admitted under vascular surgery. One hundred and fifty-two GeriCO-V patients were compared with 150 patients in the pre- GeriCO-V group. The primary outcomes were hospital-acquired geriatric syndromes, delirium, and length of stay. Results The GeriCO-V group had more frail (43% vs 30%), urgently admitted (47% vs 37%), and non-operative patients (34% vs 22%). These differences were attributed to COVID-19. GeriCO-V patients had fewer hospital-acquired geriatric syndromes (49% vs 65%; P =.005) and incident delirium (3% vs 10%; P = .02), in unadjusted and adjusted analyses. Cardiac (5% vs 20%; P <.001) and infective complications (3% vs 8%]; P = .04) were fewer in the GeriCO-V group. LOS was unchanged. Frail patients in the GeriCO-V group experienced significantly less geriatric syndromes and delirium. Conclusions The Gerico-V model of care led to reductions in hospital-acquired geriatric syndromes, delirium, and cardiac and infective complications. These benefits were seen in frail patients. The intervention requires close collaboration between surgeons and geriatricians, and may be translated to other surgical specialties.
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Affiliation(s)
| | - Sarah Aitken
- University of Sydney, Concord, New South Wales, Australia
| | - Sue Monaro
- Concord Hospital, Concord, New South Wales, Australia
| | - John Cullen
- Concord Hospital, Concord, New South Wales, Australia
| | | | - Sarah Hilmer
- The University of Sydney, St Leonards, New South Wales, Australia
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Liu Q, Schwartz JB, Slattum PW, Lau SWJ, Guinn D, Madabushi R, Burckart G, Califf R, Cerreta F, Cho C, Cook J, Gamerman J, Goldsmith P, van der Graaf PH, Gurwitz JH, Haertter S, Hilmer S, Huang SM, Inouye SK, Kanapuru B, Pirmohamed M, Posner P, Radziszewska B, Keipp Talbot H, Temple R. Roadmap to 2030 for Drug Evaluation in Older Adults. Clin Pharmacol Ther 2021; 112:210-223. [PMID: 34656074 DOI: 10.1002/cpt.2452] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
Changes that accompany older age can alter the pharmacokinetics (PK), pharmacodynamics (PD), and likelihood of adverse effects (AEs) of a drug. However, older adults, especially the oldest or those with multiple chronic health conditions, polypharmacy, or frailty, are often under-represented in clinical trials of new drugs. Deficits in the current conduct of clinical evaluation of drugs for older adults and potential steps to fill those knowledge gaps are presented in this communication. The most important step is to increase clinical trial enrollment of older adults who are representative of the target treatment population. Unnecessary eligibility criteria should be eliminated. Physical and financial barriers to participation should be removed. Incentives could be created for inclusion of older adults. Enrollment goals should be established based on intended treatment indications, prevalence of the condition, and feasibility. Relevant clinical pharmacology data need to be obtained early enough to guide dosing and reduce risk for participation of older adults. Relevant PK and PD data as well as patient-centered outcomes should be measured during trials. Trial data should be analyzed for differences in PK, PD, effectiveness, and safety arising from differences in age or from the presence of conditions common in older adults. Postmarket evaluations with real-world evidence and drug labeling updates throughout the product lifecycle reflecting new knowledge are also needed. A comprehensive plan is needed to ensure adequate evaluation of the safety and effectiveness of drugs in older adults.
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Affiliation(s)
- Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Janice B Schwartz
- Departments of Medicine, Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Patricia W Slattum
- Department of Pharmacotherapy and Outcomes Science and Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - S W Johnny Lau
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Califf
- Verily and Google Health (Alphabet), South San Francisco, California, USA
| | - Francesca Cerreta
- Portfolio office, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Carolyn Cho
- Oncology Early Development and Translational Research, Merck & Co., Kenilworth, New Jersey, USA
| | - Jack Cook
- Department of Clinical Pharmacology, Pfizer Global Research and Development, Groton, Connecticut, USA
| | - Jamie Gamerman
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul Goldsmith
- Lilly Exploratory Medicine and Pharmacology, Bracknell, UK
| | | | - Jerry H Gurwitz
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA
| | - Sebastian Haertter
- Boehringer Ingelheim Pharma, Translational Medicine & Clinical Pharmacology, Ingelheim, Germany
| | - Sarah Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Shiew-Mei Huang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston. Massachusetts, USA
| | - Bindu Kanapuru
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Phil Posner
- Patient-Centered Outcomes Research Institute Ambassador, Gainesville, Florida, USA
| | - Barbara Radziszewska
- National Institute of Aging, National Institute of Health, Bethesda, Maryland, USA
| | - H Keipp Talbot
- Departments of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Temple
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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12
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Magin P, Quain D, Tapley A, van Driel M, Davey A, Holliday E, Ball J, Kaniah A, Turner R, Spike N, FitzGerald K, Hilmer S. Deprescribing in older patients by early-career general practitioners: Prevalence and associations. Int J Clin Pract 2021; 75:e14325. [PMID: 33960089 DOI: 10.1111/ijcp.14325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 12/09/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
RATIONALE AND AIMS Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs. METHODS A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines. RESULTS One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration). CONCLUSION These findings will have important implications for the education of GPs in deprescribing as a clinical skill.
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Affiliation(s)
- Parker Magin
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Debbie Quain
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Amanda Tapley
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Mieke van Driel
- Discipline of General Practice and Primary Care Clinical Unit, Faculty of Medicine, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Andrew Davey
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Jean Ball
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ashwin Kaniah
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Rachel Turner
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Medical Education, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT) Churchill, Churchill, Vic, Australia
- Department of General Practice and Primary Health Care Carlton, University of Melbourne, Melbourne, Vic, Australia
| | | | - Sarah Hilmer
- University of Sydney and Royal North Shore Hospital, Kolling Institute, St Leonards, NSW, Australia
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13
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Ng B, Duong M, Lo S, Le Couteur D, Hilmer S. Deprescribing perceptions and practice: Reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module. Res Social Adm Pharm 2021; 17:1997-2005. [PMID: 33773940 DOI: 10.1016/j.sapharm.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 11/16/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing. OBJECTIVES 1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students. METHODS A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module. RESULTS Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions. CONCLUSIONS Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.
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Affiliation(s)
- Brendan Ng
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia; Capital and Coast District Health Board, Wellington, New Zealand.
| | - Mai Duong
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Sarita Lo
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - David Le Couteur
- University of Sydney and Concord Hospital, Centre for Education and Research on Ageing, Concord, New South Wales, Australia
| | - Sarah Hilmer
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
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14
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Thillainadesan J, Jansen J, Close J, Hilmer S, Naganathan V. Geriatrician perspectives on perioperative care: a qualitative study. BMC Geriatr 2021; 21:68. [PMID: 33468061 PMCID: PMC7816344 DOI: 10.1186/s12877-021-02019-x] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022] Open
Abstract
Background Perioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services. Methods A qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach. Results Geriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development. Conclusions Geriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02019-x.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia. .,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia. .,Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia.
| | - Jesse Jansen
- Centre Wiser Healthcare, and Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jacqui Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, and Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
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15
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Sawan M, Jeon YH, Bond C, Chen T, Hilmer S, Gnjidic D. Caregivers’ Perspectives of Medication Management Advice for People With Dementia at Hospital Discharge. Innov Aging 2020. [PMCID: PMC7740337 DOI: 10.1093/geroni/igaa057.667] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
People with dementia admitted to hospitals are more likely to be exposed to inappropriate polypharmacy and experience worse outcomes than people without dementia. Family and informal caregivers play an important role in managing medications across transitions of care; however, studies describing the experiences of medication guidance provided to caregivers at hospital discharge are limited. We have explored caregivers’ perceptions on the quality of and factors that influence caregiver participation in medication guidance at discharge. A qualitative approach using semi-structured interviews was conducted with 29 caregivers of people with dementia across Australia by telephone. Purposive sampling was used to ensure maximum variation of diverse perspectives. Content analysis was used to derive themes. Three themes were derived from analysis: inconsistent approaches to provision of medication information at discharge, caregiver awareness to advocate for the care recipient and managing competing priorities. Some caregivers reported inadequate information was provided because the information was communicated to the patient without the caregiver being present. Other caregivers stated a medication list, discharge summary and discussion with a healthcare profession provided useful information. Caregiver involvement in discussions on medication guidance at discharge was influenced by caregiver awareness to advocate for the care recipient to ensure medication safety and managing competing priorities at the time of discharge to manage stress. Caregivers flagged the need to establish structured caregiver education at discharge and community-based services to manage medications safely. Future studies are needed to explore development of resources to caregiver encourage participation during medication guidance at discharge.
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Affiliation(s)
- Mouna Sawan
- The University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Yun-Hee Jeon
- The University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Christine Bond
- University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Timothy Chen
- The University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Danijela Gnjidic
- The University of Sydney, Camperdown, Sydney, New South Wales, Australia
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16
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Eroli F, Johnell K, Latorre Leal M, Adamo C, Hilmer S, Wastesson JW, Cedazo-Minguez A, Maioli S. Chronic polypharmacy impairs explorative behavior and reduces synaptic functions in young adult mice. Aging (Albany NY) 2020; 12:10147-10161. [PMID: 32445552 PMCID: PMC7346056 DOI: 10.18632/aging.103315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/05/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022]
Abstract
A major challenge in the health care system is the lack of knowledge about the possible harmful effects of multiple drug treatments in old age. The present study aims to characterize a mouse model of polypharmacy, in order to investigate whether long-term exposure to multiple drugs could lead to adverse outcomes. To this purpose we selected five drugs from the ten most commonly used by older adults in Sweden (metoprolol, paracetamol, aspirin, simvastatin and citalopram). Five-month-old wild type male mice were fed for eight weeks with control or polypharmacy diet. We report for the first time that young adult polypharmacy-treated mice showed a significant decrease in exploration and spatial working memory compared to the control group. This memory impairment was further supported by a significant reduction of synaptic proteins in the hippocampus of treated mice. These novel results suggest that already at young adult age, use of polypharmacy affects explorative behavior and synaptic functions. This study underlines the importance of investigating the potentially negative outcomes from concomitant administration of different drugs, which have been poorly explored until now. The mouse model proposed here has translatable findings and can be applied as a useful tool for future studies on polypharmacy.
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Affiliation(s)
- Francesca Eroli
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - María Latorre Leal
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden
| | - Chiara Adamo
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden
| | - Sarah Hilmer
- Kolling Institute, Royal North Shore Hosptial and University of Sydney, Clinical Pharmacology and Aged Care, Sidney, Australia
| | - Jonas W Wastesson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Angel Cedazo-Minguez
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden
| | - Silvia Maioli
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden
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17
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Dearing ME, Bowles S, Isenor J, Kits O, Kouladjian O'Donnell L, Neville H, Hilmer S, Toombs K, Sirois C, Hajizadeh M, Negus A, Rockwood K, Reeve E. Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis. BMJ Open 2020; 10:e035656. [PMID: 32086361 PMCID: PMC7044900 DOI: 10.1136/bmjopen-2019-035656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER NCT03698487.
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Affiliation(s)
- Marci Elizabeth Dearing
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan Bowles
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Olga Kits
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Kent Toombs
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Universite Laval, Québec city, Quebec, Canada
- Centre for Excellence on Aging of Quebec, Quebec Integrated University Centre for Health and Social Services of the National Capital, Québec city, Québec, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aprill Negus
- Department of Family Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Centre for Health Care of the Elderly, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Emily Reeve
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality Use of Medicines Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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18
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Jokanovic N, Aslani P, Carter S, Duong M, Gnjidic D, Jansen J, Le Couteur D, Hilmer S. Development of consumer information leaflets for deprescribing in older hospital inpatients: a mixed-methods study. BMJ Open 2019; 9:e033303. [PMID: 31831548 PMCID: PMC6924866 DOI: 10.1136/bmjopen-2019-033303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To develop information leaflets for older inpatients and/or their carers to support deprescribing of antipsychotics, benzodiazepines/Z-drugs and proton pump inhibitors (PPIs). DESIGN An iterative mixed-methods approach involving face-to-face user testing and semi-structured interviews was performed over three rounds with consumers and hospital health professionals. SETTING Sydney, New South Wales, Australia. PARTICIPANTS Thirty-seven consumers (or their carers) aged 65 years or older admitted to hospital in the previous 5 years and taking at least one regular medicine (not the medicine tested) completed user testing. Health professionals included a convenience sample of seven pharmacists and five doctors. METHODS The antipsychotic leaflet was tested in round 1 (consumers, n=10) and revised and retested in round 2 (consumers, n=9; health professionals, n=5). Findings from rounds 1 and 2 informed the design of the benzodiazepine/Z-drug and PPI leaflets tested in round 3 (benzodiazepine/Z-drug consumers, n=9; health professionals, n=7; PPI consumers, n=9). Findings from round 3 informed the final design of all leaflets. Consumer user testing involved 12-13 questions to evaluate consumers' ability to locate and understand information in the leaflet. Usability by health professionals was assessed using the System Usability Scale (SUS). RESULTS At least 80% of consumers correctly found and understood the deprescribing information in the leaflets (9 of 12 information points in round 1 (antipsychotic); 10 of 12 in round 2; 12 of 13 (benzodiazepine/Z-drug) and 11 of 12 (PPI) in round 3). Consumers perceived the leaflets to be informative, well-designed and useful aids for ongoing medication management. The SUS scores obtained from health professionals were 91.0±3.8 for the antipsychotic leaflet and 86.4±6.6 for the benzodiazepine/Z-drug leaflet, indicating excellent usability. CONCLUSIONS Understandable and easy-to-use consumer information leaflets were developed and tested by consumers and health professionals. The feasibility and utility of these leaflets to support deprescribing at transitions of care should be explored in clinical practice.
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Affiliation(s)
- Natali Jokanovic
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Parisa Aslani
- Sydney Pharmacy School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sophie Carter
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Mai Duong
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Sydney Pharmacy School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - David Le Couteur
- Centre for Education and Research on Ageing, Concord Hospital, Sydney, New South Wales, Australia
- Concord Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sarah Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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19
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Affiliation(s)
- Claire Harrison
- Humphries Road Medical Centre, Frankston South, Victoria.,Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria.,Royal North Shore Hospital, Sydney.,Northern Clinical School, Faculty of Medicine and Health, University of Sydney
| | - Sarah Hilmer
- Humphries Road Medical Centre, Frankston South, Victoria.,Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria.,Royal North Shore Hospital, Sydney.,Northern Clinical School, Faculty of Medicine and Health, University of Sydney
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20
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Baysari MT, Duong M, Zheng WY, Nguyen A, Lo S, Ng B, Ritchie A, Le Couteur D, McLachlan A, Bennett A, Hilmer S. Delivering the right information to the right person at the right time to facilitate deprescribing in hospital: a mixed methods multisite study to inform decision support design in Australia. BMJ Open 2019; 9:e030950. [PMID: 31562155 PMCID: PMC6773288 DOI: 10.1136/bmjopen-2019-030950] [Citation(s) in RCA: 9] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To inform the design of electronic decision support (EDS) to facilitate deprescribing in hospitals we set out to (1) explore the current processes of in-hospital medicines review, deprescribing and communication of deprescribing decisions with the patient's general practitioner (GP), (2) identify barriers to undertaking these tasks and (3) determine user preferences for EDS. DESIGN Multimethod, multisite study comprising observations, semistructured interviews and focus groups. SETTING General medicine, geriatric medicine and rehabilitation wards at six hospitals in two local health districts in Sydney, Australia and primary care practices in one primary healthcare district in Sydney, Australia. PARTICIPANTS 149 participants took part in observations, interviews and focus groups, including 69 hospital doctors, 13 nurses, 55 pharmacists and 12 GPs. MAIN OUTCOME MEASURES Observational data on who was involved in medicines review and deprescribing, when medicines review took place, and what artefacts (eg, forms) were used. Participants reported perceptions of medicines review, polypharmacy and deprescribing and preferences for EDS. RESULTS Deprescribing, undertaken during medicines review, was typically performed by a junior doctor, following a decision to deprescribe by a senior doctor. Key barriers to deprescribing included a perception that deprescribing was not the responsibility of hospital doctors, a lack of confidence among junior doctors and pharmacists in broaching this topic with senior doctors and a lack of patient engagement in the deprescribing process. In designing EDS, the tools, likely to be used by junior doctors, pharmacists and nurses, should be available throughout the hospitalisation and should comprise non-interruptive evidence-based guidance on why and how to deprescribe. CONCLUSIONS Deprescribing decisions are complex and influenced by multiple factors. The implementation of EDS alone is unlikely to address all barriers identified. To achieve sustained improvements in monitoring of polypharmacy and subsequent deprescribing, a multifaceted intervention is needed.
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Affiliation(s)
- Melissa T Baysari
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Mai Duong
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
| | - Wu Yi Zheng
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Amy Nguyen
- Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sarita Lo
- Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
| | - Brendan Ng
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, New South Wales, Australia
- Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David Le Couteur
- University of Sydney Centre for Education and Research on Ageing, Concord, New South Wales, Australia
| | - Andrew McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Sarah Hilmer
- Department of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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21
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Baysari MT, Zheng WY, Li L, Westbrook J, Day RO, Hilmer S, Van Dort BA, Hargreaves A, Kennedy P, Monaghan C, Doherty P, Draheim M, Nair L, Samson R. Optimising computerised decision support to transform medication safety and reduce prescriber burden: study protocol for a mixed-methods evaluation of drug-drug interaction alerts. BMJ Open 2019; 9:e026034. [PMID: 31427312 PMCID: PMC6701635 DOI: 10.1136/bmjopen-2018-026034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Drug-drug interaction (DDI) alerts in hospital electronic medication management (EMM) systems are generated at the point of prescribing to warn doctors about potential interactions in their patients' medication orders. This project aims to determine the impact of DDI alerts on DDI rates and on patient harm in the inpatient setting. It also aims to identify barriers and facilitators to optimal use of alerts, quantify the alert burden posed to prescribers with implementation of DDI alerts and to develop algorithms to improve the specificity of DDI alerting systems. METHODS AND ANALYSIS A controlled pre-post design will be used. Study sites include six major referral hospitals in two Australian states, New South Wales and Queensland. Three hospitals will act as control sites and will implement an EMM system without DDI alerts, and three as intervention sites with DDI alerts. The medical records of 280 patients admitted in the 6 months prior to and 6 months following implementation of the EMM system at each site (total 3360 patients) will be retrospectively reviewed by study pharmacists to identify potential DDIs, clinically relevant DDIs and associated patient harm. To identify barriers and facilitators to optimal use of alerts, 10-15 doctors working at each intervention hospital will take part in observations and interviews. Non-identifiable DDI alert data will be extracted from EMM systems 6-12 months after system implementation in order to quantify alert burden on prescribers. Finally, data collected from chart review and EMM systems will be linked with clinically relevant DDIs to inform the development of algorithms to trigger only clinically relevant DDI alerts in EMM systems. ETHICS AND DISSEMINATION This research was approved by the Hunter New England Human Research Ethics Committee (18/02/21/4.07). Study results will be published in peer-reviewed journals and presented at local and international conferences and workshops.
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Affiliation(s)
- Melissa T Baysari
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Wu Yi Zheng
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Richard O Day
- St Vincent's Clinical School, UNSW Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Bethany Annemarie Van Dort
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | | | - Corey Monaghan
- eHealth QLD, Queensland Department of Health, Brisbane, Queensland, Australia
| | - Paula Doherty
- John Hunter Hospital, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Michael Draheim
- Metro South Health Service District, Brisbane, Queensland, Australia
| | - Lucy Nair
- Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Ruby Samson
- Nepean Hospital, Blue Mountains, New South Wales, Australia
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22
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Jeon YH, Simpson JM, Low LF, Woods R, Norman R, Mowszowski L, Clemson L, Naismith SL, Brodaty H, Hilmer S, Amberber AM, Gitlin LN, Szanton S. A pragmatic randomised controlled trial (RCT) and realist evaluation of the interdisciplinary home-bAsed Reablement program (I-HARP) for improving functional independence of community dwelling older people with dementia: an effectiveness-implementation hybrid design. BMC Geriatr 2019; 19:199. [PMID: 31357949 PMCID: PMC6664757 DOI: 10.1186/s12877-019-1216-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 02/22/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background A major gap exists internationally in providing support to maintain functional and social independence of older people with dementia living at home. This project evaluates a model of care that integrates evidence-based strategies into a person-centred interdisciplinary rehabilitation package: Interdisciplinary Home-bAsed Reablement Program (I-HARP). Two central aims are: 1) to determine the effectiveness of I-HARP on functional independence, mobility, quality of life and depression among people with dementia, their home environmental safety, carer burden and quality of life, and I-HARP cost-effectiveness; and 2) to evaluate the processes, outcomes and influencing factors of the I-HARP implementation. Methods I-HARP is a 4-month model of care, integrated in community aged care services and hospital-based community geriatric services, and consists of: 1) 8–12 home visits, tailored to the individual client’s needs, by an occupational therapist, registered nurse, and other allied health staff; 2) minor home modifications/assistive devices to the value of <A$1000 per participant; and 3) three individual carer support sessions. The overarching design is a mixed-methods action research approach, consisting of a multi-centre pragmatic parallel-arm randomised controlled trial (RCT) and realist evaluation, conducted in two phases. Participants include 176 dyads (person aged > 60 years with mild to moderate dementia and his/her carer). During Phase I, I-HARP advisory group is established and training of I-HARP interventionists is completed, and the effectiveness of I-HARP is examined using a pragmatic RCT. Phase II, conducted concurrently with Phase I, focuses on the process evaluation of the I-HARP implementation using a realist approach. Semi-structured interviews with participants and focus groups with I-HARP interventionists and participating site managers will provide insights into the contexts, mechanisms and outcomes of I-HARP. Discussion I-HARP is being evaluated within the real-world systems of hospital-based and community-based aged care services in Australia. Future directions and strategies for reablement approaches to care for community dwelling people living with dementia, will be developed. The study will provide evidence to inform key stakeholders in their decision making and the use/delivery of the program, as well as influence future systems-thinking and changes for dementia care. Trial registration Australian New Zealand Clinical Trial Registry ACTR N12618000600246 (approved 18/04/2018).
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Affiliation(s)
- Yun-Hee Jeon
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, 88 Mallett Street - Building M02, Camperdown, Sydney, NSW, Australia.
| | - Judy M Simpson
- Sydney School of Public Health, The University of Sydney, Camperdown, Australia
| | - Lee-Fay Low
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | | | | | - Loren Mowszowski
- Brain and Mind Centre and School of Psychology, The University of Sydney, Sydney, Australia
| | - Lindy Clemson
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Sharon L Naismith
- Brain and Mind Centre, Charles Perkins Centre and School of Psychology, The University of Sydney, Sydney, Australia
| | - Henry Brodaty
- CHeBA (Centre for Healthy Brain Ageing), School of Psychiatry, UNSW, Sydney, Australia
| | - Sarah Hilmer
- Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney and Royal North Shore Hospital, St Leonards, NSW, Australia
| | | | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Sarah Szanton
- Johns Hopkins School of Nursing, Johns Hopkins School of Public Health, Baltimore, MD, USA
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23
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Thillainadesan J, Hilmer S, Close J, Kearney L, Naganathan V. Geriatric medicine services for older surgical patients in acute hospitals: Results from a binational survey. Australas J Ageing 2019; 38:278-283. [DOI: 10.1111/ajag.12675] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/19/2019] [Accepted: 04/30/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine Concord Hospital Sydney New South Wales Australia
- Concord Clinical School University of Sydney Sydney New South Wales Australia
- Centre for Education and Research on Ageing Ageing and Alzheimers Institute Sydney New South Wales Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research Sydney Medical School Royal North Shore Hospital University of Sydney Sydney New South Wales Australia
| | - Jacqui Close
- Balance and Injury Research Centre Neuroscience Research Australia University of New South Wales Sydney New South Wales Australia
- Prince of Wales Clinical School University of New South Wales Sydney New South Wales Australia
| | - Leanne Kearney
- Centre for Education and Research on Ageing Ageing and Alzheimers Institute Sydney New South Wales Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine Concord Hospital Sydney New South Wales Australia
- Concord Clinical School University of Sydney Sydney New South Wales Australia
- Centre for Education and Research on Ageing Ageing and Alzheimers Institute Sydney New South Wales Australia
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24
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Kröger E, Simard M, Sirois MJ, Giroux M, Sirois C, Kouladjian-O'Donnell L, Reeve E, Hilmer S, Carmichael PH, Émond M. Is the Drug Burden Index Related to Declining Functional Status at Follow-up in Community-Dwelling Seniors Consulting for Minor Injuries? Results from the Canadian Emergency Team Initiative Cohort Study. Drugs Aging 2019; 36:73-83. [PMID: 30378088 DOI: 10.1007/s40266-018-0604-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research. OBJECTIVES We aimed to assess the contribution of the DBI to functional decline in the CETI cohort. METHODS CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment. RESULTS The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered 'patients who decline' at 3 or 6 months' follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06). CONCLUSIONS ED visits are considered missed opportunities for optimal care interventions in seniors; Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.
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Affiliation(s)
- Edeltraut Kröger
- Faculté de pharmacie, Université Laval, Québec, Canada. .,Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada. .,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada.
| | - Marilyn Simard
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Faculté de médecine, Université Laval, Québec, Canada
| | - Marie-Josée Sirois
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Faculté de médecine, Université Laval, Québec, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada
| | - Marianne Giroux
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada
| | - Caroline Sirois
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Faculté de médecine, Université Laval, Québec, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada
| | - Lisa Kouladjian-O'Donnell
- NHMRC Cognitive Decline Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Kolling Institute of Medical Research, University of Sydney and Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Kolling Institute of Medical Research, University of Sydney and Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sarah Hilmer
- NHMRC Cognitive Decline Partnership Centre, University of Sydney, Sydney, NSW, Australia.,Kolling Institute of Medical Research, University of Sydney and Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada
| | - Marcel Émond
- Centre d'excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN), Québec, Canada.,Faculté de médecine, Université Laval, Québec, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du Centre Hospitalier Universitaire (CHU) de Québec, Québec, Canada
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25
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Mach J, Gemikonakli G, Kane A, Howlett S, deCabo R, Le Couteur D, Hilmer S. THE EFFECT OF CHRONIC POLYPHARMACY, THE DRUG BURDEN INDEX (DBI) AND DEPRESCRIBING ON PHYSICAL FUNCTION IN AGED MICE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.389] [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: 11/14/2022] Open
Affiliation(s)
- J Mach
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
| | - G Gemikonakli
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
| | - A Kane
- Harvard Medical School, Boston, USA
| | - S Howlett
- Department of Pharmacology, Dalhousie University
| | - R deCabo
- National Institute on Aging, National Institute of Health, Maryland, USA
| | | | - S Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
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26
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Tran T, Mach J, Gemikonakli G, Howlett S, deCabo R, Le Couteur D, Hilmer S. EFFECT OF LONG-TERM POLYPHARMACY AND THE DRUG BURDEN INDEX (DBI) ON CARDIAC FUNCTION AND FIBROSIS IN AGED MICE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.371] [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: 11/13/2022] Open
Affiliation(s)
| | - J Mach
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
| | | | - S Howlett
- Department of Pharmacology, Dalhousie University
| | - R deCabo
- National Institute on Aging, National Institute of Health, Maryland, USA
| | | | - S Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
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27
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Gemikonakli G, Mach J, Tran T, Howlett S, deCabo R, Le Couteur D, Hilmer S. EFFECT OF CHRONIC POLYPHARMACY AND THE DRUG BURDEN INDEX (DBI) ON MUSCLE FUNCTION AND STRUCTURE IN AGED MICE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.369] [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: 11/13/2022] Open
Affiliation(s)
| | - J Mach
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
| | | | - S Howlett
- Department of Pharmacology, Dalhousie University
| | - R deCabo
- National Institute on Aging, National Institute of Health, Maryland, USA
| | | | - S Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney
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28
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Sawan M, O’Donnell LK, Reeve E, Gnjidic D, Chen T, Kelly P, Bell JS, Hilmer S. Implementation of the goal-directed medication review electronic decision support system (G-MEDSS). Res Social Adm Pharm 2018. [DOI: 10.1016/j.sapharm.2018.05.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Brodaty H, Aerts L, Harrison F, Jessop T, Cations M, Chenoweth L, Shell A, Popovic GC, Heffernan M, Hilmer S, Sachdev PS, Draper B. Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study. J Am Med Dir Assoc 2018; 19:592-600.e7. [DOI: 10.1016/j.jamda.2018.05.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 04/08/2018] [Accepted: 05/01/2018] [Indexed: 11/28/2022]
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30
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Vu HTT, Nguyen TX, Nguyen TN, Nguyen AT, Cumming R, Hilmer S, Pham T. Prevalence of frailty and its associated factors in older hospitalised patients in Vietnam. BMC Geriatr 2017; 17:216. [PMID: 28923012 PMCID: PMC5603186 DOI: 10.1186/s12877-017-0609-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 04/02/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
Background Frailty is an emerging issue in geriatrics and gerontology. The prevalence of frailty is increasing as the population ages. Like many developing countries, Vietnam has a rapidly ageing population. However, there have been no studies about frailty in older people in Vietnam. This study aims to investigate the prevalence of frailty and its associated factors in older hospitalised patients at the National Geriatric Hospital in Hanoi, Vietnam. Methods Prospective observational study in inpatients aged ≥60 years at the National Geriatric Hospital in Hanoi, Vietnam from 4/2015 to 10/2015. Frailty was assessed using the Reported Edmonton Frail Scale (REFS) and Fried frailty phenotype. Results A total of 461 patients were recruited (56.8% female, mean age 76.2 ± 8.9 years). The prevalence of frailty was 31.9% according to the REFS. Using the Fried frailty criteria, the percentages of non-frail, pre-frail and frail participants were 24.5, 40.1 and 35.4%, respectively. Factors associated with frailty defined by REFS were age (OR 1.05 per year, 95% CI 1.03–1.08), poor reported nutritional status (OR 4.51, 95% CI 2.15–9.44), and not finishing high school (OR 2.18, 95% CI 1.37–3.46). Factors associated with frailty defined by the Fried frailty criteria included age (OR 1.07 per year, 95% CI 1.05–1.10), poor reported nutritional status (OR 2.96, 95%CI 1.43–6.11), not finishing high school (OR 1.58, 95% CI 1.01–2.46) and cardiovascular disease (OR 1.76, 95% CI 1.16–2.67). Conclusions While further studies are needed to examine the impact of frailty on outcomes in Vietnam, the observed high prevalence of frailty in older inpatients is likely to have implications for health policy and planning for the ageing population in Vietnam.
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Affiliation(s)
- Huyen Thi Thanh Vu
- Department of Gerontology, Hanoi Medical University, Hanoi, Vietnam. .,The National Geriatric Hospital, 01 Ton That Tung, Hanoi, Vietnam.
| | | | - Tu N Nguyen
- Department of Gerontology, Hanoi Medical University, Hanoi, Vietnam.,The National Geriatric Hospital, 01 Ton That Tung, Hanoi, Vietnam
| | - Anh Trung Nguyen
- The National Geriatric Hospital, 01 Ton That Tung, Hanoi, Vietnam
| | - Robert Cumming
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Sarah Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Thang Pham
- Department of Gerontology, Hanoi Medical University, Hanoi, Vietnam.,The National Geriatric Hospital, 01 Ton That Tung, Hanoi, Vietnam
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31
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Bennett A, Chow CK, Chou M, Dehbi HM, Webster R, Salam A, Patel A, Neal B, Peiris D, Thakkar J, Chalmers J, Nelson M, Reid C, Hillis GS, Woodward M, Hilmer S, Usherwood T, Thom S, Rodgers A. Efficacy and Safety of Quarter-Dose Blood Pressure-Lowering Agents: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Hypertension 2017; 70:85-93. [PMID: 28584013 DOI: 10.1161/hypertensionaha.117.09202] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 02/06/2017] [Revised: 02/26/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
There is a critical need for blood pressure-lowering strategies that have greater efficacy and minimal side effects. Low-dose combinations hold promise in this regard, but there are few data on very-low-dose therapy. We, therefore, conducted a systematic review and meta-analysis of randomized controlled trials with at least one quarter-dose and one placebo and standard-dose monotherapy arm. A search was conducted of Medline, Embase, Cochrane Registry, Food and Drug Administration, and European Medicinal Agency websites. Data on blood pressure and adverse events were pooled using a fixed-effect model, and bias was assessed using Cochrane risk of bias. The review included 42 trials involving 20 284 participants. Thirty-six comparisons evaluated quarter-dose with placebo and indicated a blood pressure reduction of -4.7/-2.4 mm Hg (P<0.001). Six comparisons were of dual quarter-dose therapy versus placebo, observing a -6.7/ -4.4 mm Hg (P<0.001) blood pressure reduction. There were no trials of triple quarter-dose combination versus placebo, but one quadruple quarter-dose study observed a blood pressure reduction of -22.4/-13.1 mm Hg versus placebo (P<0.001). Compared with standard-dose monotherapy, the blood pressure differences achieved by single (37 comparisons), dual (7 comparisons), and quadruple (1 trial) quarter-dose combinations were +3.7/+2.6 (P<0.001), +1.3/-0.3 (NS), and -13.1/-7.9 (P<0.001) mm Hg, respectively. In terms of adverse events, single and dual quarter-dose therapy was not significantly different from placebo and had significantly fewer adverse events compared with standard-dose monotherapy. Quarter-dose combinations could provide improvements in efficacy and tolerability of blood pressure-lowering therapy.
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Affiliation(s)
- Alexander Bennett
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Clara K Chow
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Michael Chou
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Hakim-Moulay Dehbi
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Ruth Webster
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Abdul Salam
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Anushka Patel
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Bruce Neal
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - David Peiris
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Jay Thakkar
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - John Chalmers
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Mark Nelson
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Christopher Reid
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Graham S Hillis
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Mark Woodward
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Sarah Hilmer
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Tim Usherwood
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Simon Thom
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.)
| | - Anthony Rodgers
- From the George Institute for Global Health (A.B., C.K.C., R.W., A.S., A.P., B.N., D.P., J.T., J.C., M.W., A.R.) and Charles Perkins Centre (C.K.C., B.N.), University of Sydney, New South Wales, Australia; Westmead Hospital, Sydney, New South Wales, Australia (C.K.C., J.T.); The University of Sydney, New South Wales, Australia (S.H., T.U., A.R.); The University of Western Australia, Perth (G.S.H.); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (M.C.); Cancer Research UK and UCL Cancer Trials Centre, University College London, United Kingdom (H.-M.D.); Imperial College, London, United Kingdom (B.N., S.T.); Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.N.); Curtin University, Perth, Australia (C.R.); and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (A.P., B.N.).
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Affiliation(s)
- Angela Wu
- Faculty of Pharmacy; University of Sydney; Sydney Australia
| | - Emily Reeve
- Sydney Medical School; University of Sydney; Sydney Australia
- Cognitive Decline Partnership Centre; Kolling Institute of Medical Research; Northern Clinical School; University of Sydney; St Leonards Australia
| | - Sarah Hilmer
- Sydney Medical School; University of Sydney; Sydney Australia
- Cognitive Decline Partnership Centre; Kolling Institute of Medical Research; Northern Clinical School; University of Sydney; St Leonards Australia
- Departments of Clinical Pharmacology and Aged Care; Royal North Shore Hospital; Sydney Australia
| | - Danijela Gnjidic
- Faculty of Pharmacy; University of Sydney; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
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Affiliation(s)
- Emily Reeve
- Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, NSW, Australia. .,Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Sarah Hilmer
- Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, NSW, Australia
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Chow CK, Thakkar J, Bennett A, Hillis G, Burke M, Usherwood T, Vo K, Rogers K, Atkins E, Webster R, Chou M, Dehbi HM, Salam A, Patel A, Neal B, Peiris D, Krum H, Chalmers J, Nelson M, Reid CM, Woodward M, Hilmer S, Thom S, Rodgers A. Quarter-dose quadruple combination therapy for initial treatment of hypertension: placebo-controlled, crossover, randomised trial and systematic review. Lancet 2017; 389:1035-1042. [PMID: 28190578 DOI: 10.1016/s0140-6736(17)30260-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/06/2017] [Accepted: 01/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Globally, most patients with hypertension are treated with monotherapy, and control rates are poor because monotherapy only reduces blood pressure by around 9/5 mm Hg on average. There is a pressing need for blood pressure-control strategies with improved efficacy and tolerability. We aimed to assess whether ultra-low-dose combination therapy could meet these needs. METHODS We did a randomised, placebo-controlled, double-blind, crossover trial of a quadpill-a single capsule containing four blood pressure-lowering drugs each at quarter-dose (irbesartan 37·5 mg, amlodipine 1·25 mg, hydrochlorothiazide 6·25 mg, and atenolol 12·5 mg). Participants with untreated hypertension were enrolled from four centres in the community of western Sydney, NSW, Australia, mainly by general practitioners. Participants were randomly allocated by computer to either the quadpill or matching placebo for 4 weeks; this treatment was followed by a 2-week washout, then the other study treatment was administered for 4 weeks. Study staff and participants were unaware of treatment allocations, and masking was achieved by use of identical opaque capsules. The primary outcome was placebo-corrected 24-h systolic ambulatory blood pressure reduction after 4 weeks and analysis was by intention to treat. We also did a systematic review of trials evaluating the efficacy and safety of quarter-standard-dose blood pressure-lowering therapy against placebo. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614001057673. The trial ended after 1 year and this report presents the final analysis. FINDINGS Between November, 2014, and December, 2015, 55 patients were screened for our randomised trial, of whom 21 underwent randomisation. Mean age of participants was 58 years (SD 11) and mean baseline office and 24-h systolic and diastolic blood pressure levels were 154 (14)/90 (11) mm Hg and 140 (9)/87 (8) mm Hg, respectively. One individual declined participation after randomisation and two patients dropped out for administrative reasons. The placebo-corrected reduction in systolic 24-h blood pressure with the quadpill was 19 mm Hg (95% CI 14-23), and office blood pressure was reduced by 22/13 mm Hg (p<0·0001). During quadpill treatment, 18 (100%) of 18 participants achieved office blood pressure less than 140/90 mm Hg, compared with six (33%) of 18 during placebo treatment (p=0·0013). There were no serious adverse events and all patients reported that the quadpill was easy to swallow. Our systematic review identified 36 trials (n=4721 participants) of one drug at quarter-dose and six trials (n=312) of two drugs at quarter-dose, against placebo. The pooled placebo-corrected blood pressure-lowering effects were 5/2 mm Hg and 7/5 mm Hg, respectively (both p<0·0001), and there were no side-effects from either regimen. INTERPRETATION The findings of our small trial in the context of previous randomised evidence suggest that the benefits of quarter-dose therapy could be additive across classes and might confer a clinically important reduction in blood pressure. Further examination of the quadpill concept is needed to investigate effectiveness against usual treatment options and longer term tolerability. FUNDING National Heart Foundation, Australia; University of Sydney; and National Health and Medical Research Council of Australia.
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Affiliation(s)
- Clara K Chow
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.
| | - Jay Thakkar
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Alex Bennett
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Graham Hillis
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; The University of Western Australia, Perth, WA, Australia
| | | | | | - Kha Vo
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Kris Rogers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Emily Atkins
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Chou
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Abdul Salam
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Imperial College, London, UK; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Henry Krum
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - John Chalmers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tas, Australia
| | | | - Mark Woodward
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Sarah Hilmer
- The University of Sydney, Sydney, NSW, Australia
| | | | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
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Clemson L, Mackenzie L, Roberts C, Poulos R, Tan A, Lovarini M, Sherrington C, Simpson JM, Willis K, Lam M, Tiedemann A, Pond D, Peiris D, Hilmer S, Pit SW, Howard K, Lovitt L, White F. Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design. Implement Sci 2017; 12:12. [PMID: 28173827 PMCID: PMC5296956 DOI: 10.1186/s13012-016-0529-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 11/09/2016] [Accepted: 12/01/2016] [Indexed: 12/30/2022] Open
Abstract
Background Despite strong evidence giving guidance for effective fall prevention interventions in community-residing older people, there is currently no clear model for engaging general medical practitioners in fall prevention and routine use of allied health professionals in fall prevention has been slow, limiting widespread dissemination. This protocol paper outlines an implementation-effectiveness study of the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) intervention which has developed integrated processes and pathways to identify older people at risk of falls and engage a whole of primary care approach to fall prevention. Methods/design This protocol paper presents the iSOLVE implementation processes and change strategies and outlines the study design of a blended type 2 hybrid design. The study consists of a two-arm cluster randomized controlled trial in 28 general practices and recruiting 560 patients in Sydney, Australia, to evaluate effectiveness of the iSOLVE intervention in changing general practitioner fall management practices and reducing patient falls and the cost effectiveness from a healthcare funder perspective. Secondary outcomes include change in medications known to increase fall risk. We will simultaneously conduct a multi-methodology evaluation to investigate the workability and utility of the implementation intervention. The implementation evaluation includes in-depth interviews and surveys with general practitioners and allied health professionals to explore acceptability and uptake of the intervention, the coherence of the proposed changes for those in the work setting, and how to facilitate the collective action needed to implement changes in practice; social network mapping will explore professional relationships and influences on referral patterns; and, a survey of GPs in the geographical intervention zone will test diffusion of evidence-based fall prevention practices. The project works in partnership with a primary care health network, state fall prevention leaders, and a community of practice of fall prevention advocates. Discussion The design is aimed at providing clear direction for sustainability and informing decisions about generalization of the iSOLVE intervention processes and change strategies. While challenges exist in hybrid designs, there is a potential for significant outcomes as the iSOLVE pathways project brings together practice and research to collectively solve a major national problem with implications for policy service delivery. Trial registration Australian New Zealand Clinial Trials Registry ACTRN12615000401550
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Affiliation(s)
- Lindy Clemson
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia. .,Centre of Excellence in Population Ageing Research, Sydney, Australia.
| | - Lynette Mackenzie
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Chris Roberts
- Sydney Medical School - Northern, The University of Sydney, Sydney, Australia
| | - Roslyn Poulos
- School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Amy Tan
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Meryl Lovarini
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Cathie Sherrington
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Judy M Simpson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Karen Willis
- Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Mary Lam
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Anne Tiedemann
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Dimity Pond
- School of Medicine & Public Health, University of Newcastle, Newcastle, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Sarah Hilmer
- Sydney Medical School - Northern, The University of Sydney, Sydney, Australia.,Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Sabrina Winona Pit
- University Centre for Rural Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Fiona White
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
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Gnjidic D, Du W, Pearson SA, Hilmer S, Banks E. Ascertainment of self-reported prescription medication use compared with pharmaceutical claims data. Public Health Res Pract 2017; 27:27341702. [DOI: 10.17061/phrp27341702] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol 2016; 80:1254-68. [PMID: 27006985 DOI: 10.1111/bcp.12732] [Citation(s) in RCA: 380] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIMS The aim of this study was to identify what definitions have been published for the term 'deprescribing', and determine whether a unifying definition could be reached. A secondary aim was to uncover patterns between the published definitions which could explain any variation. METHODS Systematic literature searches were performed (earliest records to February 2014) in MEDLINE, Embase, CINAHL, Informit, Scopus and Google Scholar. The terms deprescrib* or de-prescrib* were employed as a keyword search in all fields. Conventional content analysis and word frequencies were used to identify characteristics of the definitions. Network analysis was conducted to visualize characteristic distribution across authors and articles. RESULTS Following removal of duplicates, 231 articles were retrieved, 37 of which included a definition. Eight characteristics of the definitions were identified: use of the term stop/withdraw/cease/discontinue (35 articles), aspect of prescribing included e.g. long term therapy/inappropriate medications (n = 18), use of the term 'process' or 'structured' (n = 13), withdrawal is planned/supervised/judicious (n = 11), involving multiple steps (n = 7), includes dose reduction/substitution (n = 7), desired goals/outcomes described (n = 5) and involves tapering (n = 4). Network analysis did not reveal patterns responsible for variations in previously used definitions. CONCLUSIONS These findings show that there is lack of consensus on the definition of deprescribing. This article proposes the following definition: 'Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes'. This definition has not yet been externally validated and further work is required to develop an internationally accepted and appropriate definition.
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Wu A, Reeve E, Hilmer S, Gnjidic D. Hospital pharmacists’ perspectives in optimising statin therapy in older inpatients. Res Social Adm Pharm 2016. [DOI: 10.1016/j.sapharm.2016.05.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bajorek B, Magin PJ, Hilmer S, Krass I. Utilization of antithrombotic therapy for stroke prevention in atrial fibrillation: a cross-sectional baseline analysis in general practice. J Clin Pharm Ther 2016; 41:432-40. [DOI: 10.1111/jcpt.12409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- B. Bajorek
- Graduate School of Health; University of Technology Sydney; Sydney NSW Australia
| | - P. J. Magin
- School of Medicine and Public Health; University of Newcastle; Callaghan NSW Australia
| | - S. Hilmer
- Department of Clinical Pharmacology; Royal North Shore Hospital; St. Leonards NSW Australia
| | - I. Krass
- Pharmacy; University of Sydney; Sydney NSW Australia
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Thai M, Hilmer S, Pearson SA, Reeve E, Gnjidic D. Prevalence of Potential and Clinically Relevant Statin-Drug Interactions in Frail and Robust Older Inpatients. Drugs Aging 2016; 32:849-56. [PMID: 26442861 DOI: 10.1007/s40266-015-0302-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A significant proportion of older people are prescribed statins and are also exposed to polypharmacy, placing them at increased risk of statin-drug interactions. OBJECTIVE To describe the prevalence rates of potential and clinically relevant statin-drug interactions in older inpatients according to frailty status. METHODS A cross-sectional study of patients aged ≥65 years who were prescribed a statin and were admitted to a teaching hospital between 30 July and 10 October 2014 in Sydney, Australia, was conducted. Data on socio-demographics, comorbidities and medications were collected using a standardized questionnaire. Potential statin-drug interactions were defined if listed in the Australian Medicines Handbook and three international drug information sources: the British National Formulary, Drug Interaction Facts and Drug-Reax(®). Clinically relevant statin-drug interactions were defined as interactions with the highest severity rating in at least two of the three international drug information sources. Frailty was assessed using the Reported Edmonton Frail Scale. RESULTS A total of 180 participants were recruited (median age 78 years, interquartile range 14), 35.0% frail and 65.0% robust. Potential statin-drug interactions were identified in 10% of participants, 12.7% of frail participants and 8.5% of robust participants. Clinically relevant statin-drug interactions were identified in 7.8% of participants, 9.5% of frail participants and 6.8% of robust participants. Depending on the drug information source used, the prevalence rates of potential and clinically relevant statin-drug interactions ranged between 14.4 and 35.6% and between 14.4 and 20.6%, respectively. CONCLUSION In our study of frail and robust older inpatients taking statins, the overall prevalence of potential statin-drug interactions was low and varied significantly according to the drug information source used.
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Affiliation(s)
- Michele Thai
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Sarah Hilmer
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | | | - Emily Reeve
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Danijela Gnjidic
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia.
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Bajorek B, Magin P, Hilmer S, Krass I. Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners. Australas Med J 2015; 8:357-67. [PMID: 26688698 DOI: 10.4066/amj.2015.2526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 11/09/2022]
Abstract
BACKGROUND Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care. AIMS To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care. METHODS A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas). RESULTS Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in "heart/vascular health". Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs' initiation of antithrombotic therapy were: "stroke risk"/"CHADS2 score", followed by "patients' adherence/compliance". GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding. CONCLUSION Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients' adherence to therapy a major determinant in decision-making.
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Affiliation(s)
- Beata Bajorek
- Graduate School of Health - Pharmacy, University of Technology Sydney, Sydney, NSW, Australia
| | - Parker Magin
- Discipline of General Practice, University of Newcastle, Callaghan, NSW, Australia
| | - Sarah Hilmer
- Dept. of Clinical Pharmacology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ines Krass
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia
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Gnjidic D, Naganathan V, Freedman S, Beer CE, McLachlan A, Figtree G, Hilmer S. Statin Therapy and Cognition in Older People: What is the Evidence? ACTA ACUST UNITED AC 2015; 10:185-93. [DOI: 10.2174/157488471003150820152249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/05/2014] [Accepted: 07/07/2014] [Indexed: 11/22/2022]
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Reeve E, Bell J, Hilmer S. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. ACTA ACUST UNITED AC 2015; 10:168-77. [DOI: 10.2174/157488471003150820150330] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/04/2015] [Accepted: 07/05/2015] [Indexed: 11/22/2022]
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Bennett A, Gnjidic D, Gillett M, Carroll P, Matthews S, Johnell K, Fastbom J, Hilmer S. Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging 2014; 31:225-32. [PMID: 24452921 DOI: 10.1007/s40266-013-0151-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several measures of medication exposure are associated with adverse outcomes in older people. Exposure to and the clinical outcomes of these measures in robust versus frail older inpatients are not known. OBJECTIVE In older robust and frail patients admitted to hospital after a fall, we investigated the prevalence and clinical impact of fall-risk-increasing drugs (FRIDs), total number of medications, and drug-drug interactions (DDIs). METHODS Patients ≥60 years of age admitted with a fall to a tertiary referral teaching hospital in Sydney were recruited and frailty was assessed. Data were collected at admission, discharge, and 2 months after admission. RESULTS A total of 204 patients were recruited (mean age 80.5 ± 8.3 years), with 101 robust and 103 frail. On admission, compared with the robust, frail participants had significantly higher mean ± SD number of FRIDs (frail 3.4 ± 2.2 vs. robust 1.6 ± 1.5, P < 0.0001), total number of medications (9.8 ± 4.3 vs. 4.4 ± 3.3, P < 0.0001), and DDI exposure (35 vs. 5 %, P = 0.001). Number of FRIDs on discharge was significantly associated with recurrent falls [odds ratio (OR) 1.7 (95 % confidence interval [CI] 1.3-2.1)], which were most likely to occur with 1.5 FRIDs in the frail and 2.5 FRIDs in the robust. Number of medications on discharge was also associated with recurrent falls [OR 1.2 (1.0-1.3)], but DDIs were not. CONCLUSION Exposure to FRIDs and other measures of high-risk medication exposures is common in older people admitted with falls, especially the frail. Number of FRIDs and to a lesser extent total number of medicines at discharge were associated with recurrent falls.
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Affiliation(s)
- Alexander Bennett
- University of Sydney, Northern Clinical School, Sydney, NSW, Australia,
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Reeve E, Gnjidic D, Hilmer S. The role of the OncPal deprescribing guideline in end-of-life care. Support Care Cancer 2014; 23:899. [PMID: 25245777 DOI: 10.1007/s00520-014-2445-3] [Citation(s) in RCA: 3] [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: 07/20/2014] [Accepted: 09/14/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Emily Reeve
- University of Sydney, St Leonards, NSW, Australia,
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Bajorek B, Magin P, Hilmer S, Krass I. A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: a study protocol. BMC Health Serv Res 2014; 14:55. [PMID: 24507462 PMCID: PMC3925360 DOI: 10.1186/1472-6963-14-55] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 11/04/2013] [Accepted: 01/06/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Therapy for stroke prevention in older persons with atrial fibrillation (AF) is underutilized despite evidence to support its effectiveness. To prevent stroke in this high-risk population, antithrombotic treatment is necessary. Given the challenges and inherent risks of antithrombotic therapy, decision-making is particularly complex for clinicians, necessitating comprehensive risk:benefit assessments. Targeted interventions are urgently needed to support clinicians in this context; the Computerized Antithrombotic Risk Assessment Tool (CARAT) offers a unique approach to this clinical problem. METHODS/DESIGN This study (a prospective, cluster-randomized controlled clinical trial) will be conducted across selected regions in the state of New South Wales, Australia. Fifty GPs will be randomized to either the 'intervention' or 'control' arm, with each GP recruiting 10 patients (aged ≥65 with AF); target sample size is 500 patients. GPs in the intervention arm will use CARAT during routine patient consultations to: assess risk factors for stroke, bleeding and medication misadventure; quantify the risk/benefit ratio of antithrombotic treatment, identify the recommended therapy, and decide on the treatment course, for an individual patient. CARAT will be applied by the GP at baseline and repeated at 12 months to identify any changes to treatment requirements. At baseline, the participant (patients and GPs) characteristics will be recorded, as well as relevant practice and clinical parameters. Patient follow up will occur at 1, 6, and 12 months via telephone interview to identify changes to therapy, medication side effects, or clinical events. DISCUSSION This project tests the utility of a novel decision support tool (CARAT) in improving the use of preventative therapy to reduce the significant burden of stroke. Importantly, it targets the interface of patient care (general practice), addresses the at-risk population, evaluates clinical outcomes, and offers a tool that may be sustainable via integration into prescribing software and primary care services. GP support and guidance in identifying at risk patients for the appropriate selection of therapy is widely acknowledged. This trial will evaluate the impact of CARAT on the prescription of antithrombotic therapy, its longer-term impact on clinical outcomes including stroke and bleeding, and clinicians perceived utility of CARAT in practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12613000060741.
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Affiliation(s)
- Beata Bajorek
- School of Pharmacy - Graduate School of Health, University of Technology Sydney, PO Box 123 Broadway, Sydney, New South Wales 2007, Australia.
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Sheppard M, Begg A, Hilmer S, Gnjidic D. Statins in older adults. Aust Prescr 2013. [DOI: 10.18773/austprescr.2013.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Gabb G, Hilmer S, Gnjidic D. Statins in older adults. Aust Prescr 2013. [DOI: 10.18773/austprescr.2013.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Kouladjian L, Gnjidic D, Chen T, Hilmer S. PP009—Development, validation and usability of software to calculate the drug burden index: A pilot study. Clin Ther 2013. [DOI: 10.1016/j.clinthera.2013.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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