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Dil-Nahlieli D, Ben-Yehuda A, Souroujon D, Hyam E, Shafran-Tikvah S. Validation of a novel Artificial Pharmacological Intelligence (API) system for the management of patients with polypharmacy. Res Social Adm Pharm 2024:S1551-7411(24)00117-7. [PMID: 38637208 DOI: 10.1016/j.sapharm.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 03/24/2024] [Accepted: 04/01/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE Medication management of patients with polypharmacy is highly complex. We aimed to validate a novel Artificial Pharmacological Intelligence (API) algorithm to optimize the medication review process in a comprehensive, personalized, and scalable way. MATERIALS AND METHODS The study was conducted on anonymized retrospective electronic health records (EHR) of 49 patients. Each patient's file was reviewed by the API system, a clinical pharmacist, and a judging committee. Validation was assessed by comparing the overall agreement of the judging committee (as the gold standard, blinded to the identity of the analyzer) to both the API system and clinical pharmacists' conclusions. Five medication-related problem (MRP) categories were assessed: duplication of therapy, age-related issues, incorrect dose, current side effects and future side effects' risk. For each category the overall validity parameters, agreement, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were analyzed. RESULTS The agreement between the API system and the judging committee was 93.5 % (95 % CI 92.7-94.4), while the agreement between the clinical pharmacists and the judging committee was 73.9 % (95 % CI 72.5-75.3). The PPV was 92.2 % (90.9-93.5) and NPV was 94.2 % (93.1-95.2) for the API system and 76.3 % (69.8-82.8) and 73.5 % (72.3-74.8) respectively for the clinical pharmacists. DISCUSSION AI systems can equip clinicians with sophisticated tools and scale manual processes such as comprehensive medication reviews, thus reducing MRPs and drug-related hospitalizations related to multidrug treatments. The API system validated in this study provided comprehensive, multidrug, multilayered analysis intended to bridge the innate complexity of personalized polypharmacy treatment. CONCLUSIONS The API system was validated as a tool for providing actionable clinical insights non-inferior to a manual clinical review of a clinical pharmacist. The API system showed promising results in reducing MRPs.
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Affiliation(s)
- Dorit Dil-Nahlieli
- Department of Research and Development, MDI Health Technologies, Ramat Gan, Israel.
| | - Arie Ben-Yehuda
- Department of Medicine, Hadassah Medical Center Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Eytan Hyam
- Department of Research and Development, MDI Health Technologies, Ramat Gan, Israel
| | - Sigal Shafran-Tikvah
- Nursing Division, Hadassah University Medical Center & Jerusalem College of Technology, Jerusalem, Israel
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Jungo KT, Deml MJ, Schalbetter F, Moor J, Feller M, Lüthold RV, Huibers CJA, Sallevelt BTGM, Meulendijk MC, Spruit M, Schwenkglenks M, Rodondi N, Streit S. A mixed methods analysis of the medication review intervention centered around the use of the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA) in Swiss primary care practices. BMC Health Serv Res 2024; 24:350. [PMID: 38500163 PMCID: PMC10949561 DOI: 10.1186/s12913-024-10773-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Electronic clinical decision support systems (eCDSS), such as the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) trial. METHODS We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis. RESULTS In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations. CONCLUSIONS Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs' overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports). TRIAL REGISTRATION Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018.
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Affiliation(s)
- Katharina Tabea Jungo
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
- Center for Healthcare Delivery Sciences (C4HDS), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, United States.
| | - Michael J Deml
- Institute of Sociological Research, University of Geneva, Geneva, Switzerland
| | - Fabian Schalbetter
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jeanne Moor
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Renata Vidonscky Lüthold
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Corlina Johanna Alida Huibers
- Geriatrics, Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Michiel C Meulendijk
- Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Marco Spruit
- Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden University, Leiden, Netherlands
- Leiden Institute of Advanced Computer Science (LIACS), Faculty of Science, Leiden University, Leiden, Netherlands
- Department of Information and Computing Sciences, Utrecht University, Utrecht, Netherlands
| | - Matthias Schwenkglenks
- Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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Jacobs JA, Zheutlin AR, Derington CG, King JB, Pandey A, Bress AP. Glucagon-like peptide-1 receptor agonist and sodium-glucose cotransporter 2 inhibitor use among adults with diabetes mellitus by cardiovascular-kidney disease risk: National Health and Nutrition Examination Surveys, 2015-2020. Am J Prev Cardiol 2024; 17:100624. [PMID: 38125205 PMCID: PMC10730337 DOI: 10.1016/j.ajpc.2023.100624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/19/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Glucagon-like peptide-1 receptor agonists (GLP1-RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2Is) lower adverse cardiac and kidney events among high-risk patients with diabetes mellitus (DM) and are now guideline-recommended as first-line therapy alongside metformin. However, the adoption of these new treatments from 2015 to 2020 among the highest-risk adults with DM remains unclear. Methods We performed a cross-sectional analysis of the National Health and Nutrition Examination Surveys (NHANES) 2015-2020 to estimate the use of GLP1-RAs and SGLT2Is among adults with DM overall and by level of cardiovascular and kidney risk (CKR). We defined high CKR by history of atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), heart failure, or age ≥55 years with at least 2 ASCVD risk factors (i.e., obesity, hypertension, hyperlipidemia, or current smoker). Results Overall, 2,432 participants with DM (mean age 60.6 years, 46.8 % female, 58.8 % Non-Hispanic White) were included, of which 1,869 and 563 were with and without high CKR, respectively. Participants with vs. without high CKR were more likely to be older, have higher systolic blood pressure, lower estimated glomerular filtration rate, use oral antidiabetic agents, and have health insurance. Overall, the weighted prevalence of GLP1-RA or SGLT2I was 9.0 % (95 % confidence interval [CI] 6.9-11.0): 4.8 % (95 % CI 3.6-6.1) took GLP1-RAs, and 5.1 % (95 % CI 3.3-7.0) took SGLT2Is. Use of GLP1-RAs or SGLT2Is did not differ between participants with vs. without high CKR (adjusted prevalence ratio [aPR] 1.00; 95 % CI 0.98-1.02). Participants with ASCVD were more likely to be on a GLP1-RA or SGLT2I (aPR 1.28; 95 % CI 1.25-1.31), while adults with CKD were less likely (aPR 0.84; 95 % CI 0.82-0.86). Conclusion Among US adults with DM, GLP1-RA and SGLT2I use was low regardless of CKR. Data since 2020 analyzing the utilization of GLP1-RAs and SGLT2Is among high-CKR patients with DM is needed to identify implementation strategies for increased utilization.
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Affiliation(s)
- Joshua A. Jacobs
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Alexander R. Zheutlin
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Catherine G. Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Adam P. Bress
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
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Damiaens A, Van Hecke A, Foulon V. The RESPECT-tool as a facilitator for person-centered medication reviews for nursing home residents: tool development and pilot study. Int J Clin Pharm 2023; 45:1434-1443. [PMID: 37493905 DOI: 10.1007/s11096-023-01621-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Although support is needed, no method exists to elicit and integrate personal goals into medication optimization interventions for nursing home residents. AIM To develop and evaluate a tool to (1) elicit and evaluate residents' personal goals during medication optimization, and (2) elicit involvement preferences regarding medication decision-making. METHOD A draft was composed by the research team, on which feedback was collected through four focus groups with healthcare professionals (n = 23) and pilot interviews with residents (n = 6). The tool was then pilot tested in 11 nursing homes as means to facilitate person-centered medication reviews, focusing on feasibility, appropriateness, and meaningfulness. Evaluation was performed through interviews and focus groups with residents and healthcare professionals, and reports for executed medication reviews. Interview summaries and reports were analyzed inductively. RESULTS The RESident's Participation in the Evaluation and Customization of Therapy tool (RESPECT-tool) was drafted as a modular approach of five modules. Pilot study results showed that the tool supported the formulation of personal goals. Goals resulted in changes in all aspects of the nursing home stay, indicating the tool's potential to promote person-centered care. The RESPECT-tool showed value in the context of medication optimization as it allowed to determine potential links between residents' personal goals and medication plans, and its use regularly led to medication changes. CONCLUSION A person-centered medication review facilitated by the RESPECT-tool holds a promising approach to medication optimization in nursing homes. Further research should assess impact on relevant outcomes like goal attainment, appropriateness of prescribing and quality of life.
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Affiliation(s)
- Amber Damiaens
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, O&N II, Box 521, 3000, Leuven, Belgium.
| | - Ann Van Hecke
- Department of Nursing Director, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, O&N II, Box 521, 3000, Leuven, Belgium
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Kistler EA, Clinebell K, Gannon JM, Nathaniel VI, Lupu AM, Chengappa KNR. Applying Shared Decision Making to the Process of Medication Deprescribing in Schizophrenia. Clin Ther 2023; 45:1008-1011. [PMID: 37567844 DOI: 10.1016/j.clinthera.2023.07.016] [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: 05/24/2023] [Revised: 07/11/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023]
Abstract
Deprescribing, the identification and discontinuation of medications that are no longer indicated or that cause adverse effects that outweigh clinical benefit, relies on the integration of clinical expertise and patient values using shared decision making (SDM). This case series describes the application of SDM to the process of deprescribing in patients with serious mental illness, illustrating the ways in which SDM builds a therapeutic alliance between patient, psychiatrist, family members, and other health care professionals to collaboratively develop treatment plans.
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Affiliation(s)
- Elizabeth A Kistler
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Kimberly Clinebell
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jessica M Gannon
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vernon I Nathaniel
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ana M Lupu
- Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Pharmacy and Therapeutics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - K N Roy Chengappa
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Damiaens A, Maes E, Van Roosbroek H, Van Hecke A, Foulon V. Methods to elicit and evaluate the attainment of patient goals in older adults: A scoping review. Patient Educ Couns 2022; 105:3051-3061. [PMID: 35691792 DOI: 10.1016/j.pec.2022.06.002] [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] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This scoping review aimed to identify patient goal elicitation and evaluation methods for older adults, and to investigate which methods can be used in medication optimization interventions for nursing home residents (NHRs). METHODS The Arksey and O'Malley framework guided the review. A search was launched in PubMed, Embase, CINAHL, and Web of Science. Reference selection and data extraction were performed by three independent reviewers, followed by team discussions to solve discrepancies. Inductive thematic analysis was applied to synthesize the data. Included papers were reconsidered to identify methods for medication optimization interventions for NHRs. RESULTS Ninety-six references, encompassing 38 elicitation and 12 evaluation methods, were included. Elicitation methods differed in structure, content, and patient involvement levels. Qualitative and quantitative methods were found to assess goal attainment. Five elicitation and three evaluation methods were developed for NHRs, but none of these contained a medication-related assessment. CONCLUSION A variety of goal elicitation and evaluation methods for older adults was found, but none for medication optimization interventions in NHRs. PRACTICE IMPLICATIONS A holistic approach seems important to integrate patient goals into medication optimization interventions, not limiting goal elicitation to a medication-related assessment. Also, the choice of assessor seems important to obtain patient goals.
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Affiliation(s)
- Amber Damiaens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Evelien Maes
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hanne Van Roosbroek
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Ann Van Hecke
- Department of Public Health and Primary Care, UGent, Department of Nursing Director, Ghent University Hospital Ghent, Belgium.
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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Cerfon MA, Vernaudon J, Gervais F, Morelon E, Coste MH, Krolak-Salmon P, Mouchoux C, Novais T. Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment. Nephrol Ther 2021; 18:45-51. [PMID: 34756826 DOI: 10.1016/j.nephro.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/26/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older patients with advanced chronic kidney disease may be exposed to a higher risk of adverse drug events due to chronic kidney disease and aging. The integration of clinical pharmacist into pretransplant comprehensive geriatric assessment is an opportunity to perform medication optimization. OBJECTIVE The aim was to describe drug-related problems in older patients with advanced chronic kidney disease. METHODS Observational study was conducted with retrospective data from July 2017 to April 2019. Patients≥65 years with advanced chronic kidney disease, referred by nephrologists for pretransplant comprehensive geriatric assessment were included. During medication optimization, the pharmacist evaluated the appropriateness of each medication prescribed and identified drug-related problems. Any drug-related problem identified lead to a pharmaceutical intervention. RESULTS In total, 103 patients were included (74.5±2.9 years, 26.2% female, 47.6% on dialysis). Overall, 394 drug-related problems were identified in 93.2% of patients (3.8±2.4 drug-related problems per patient) during the medication optimization. Cardiovascular medications (25.1%), antithrombotics (13.5%) and drugs for peptic ulcer and reflux disease (10.2%) were the most involved drugs in drug-related problems. Drug-related problems mainly concerned drugs without indication (27.1%), inappropriate method of administration (24.4%) and non-conformity to guidelines (20.1%). CONCLUSION A high prevalence of drug-related problems in older patients with advanced chronic kidney disease was identified during medication optimization. The systematic integration of a clinical pharmacist in the multidisciplinary team performing pretransplant comprehensive geriatric assessment may be relevant to detect inappropriate prescriptions and to prevent from adverse drug events.
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Affiliation(s)
- Marie-Anne Cerfon
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Julien Vernaudon
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Frédéric Gervais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Emmanuel Morelon
- Department of transplantation, nephrology and clinical immunology, Edouard-Herriot Hospital, University Hospital of Lyon, 69003 Lyon, France; University Lyon 1, 69008 Lyon, France
| | - Marie-Hélène Coste
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France
| | - Pierre Krolak-Salmon
- Day-care unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1028, CNRS UMR5292; Lyon neuroscience research center, brain dynamics and cognition team, 69675 Bron, France
| | - Christelle Mouchoux
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1028, CNRS UMR5292; Lyon neuroscience research center, brain dynamics and cognition team, 69675 Bron, France
| | - Teddy Novais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 69100 Villeurbanne, France; University Lyon 1, 69008 Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), University Lyon 1, 69008. Lyon, France.
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Abstract
PURPOSE Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. METHODS We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. RESULTS Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. CONCLUSION Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.
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Affiliation(s)
- Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium.
- Pharmacy Department, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
| | - Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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McFarland MS, Buck ML, Crannage E, Armistead LT, Ourth H, Finks SW, McClurg MR. Assessing the Impact of Comprehensive Medication Management on Achievement of the Quadruple Aim. Am J Med 2021; 134:456-461. [PMID: 33472055 DOI: 10.1016/j.amjmed.2020.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/01/2023]
Abstract
Nonoptimized medication regimens cost patients and payors in the United States more than $528 billion in additional health care expenses each year. Comprehensive medication management is a patient-centered approach to medication optimization delivered by a clinical pharmacist working with the patient, physicians, and other members of the health care team. Comprehensive medication management ensures medications are assessed for appropriateness, effectiveness, and safety given the patient's clinical status, comorbidities, and other medications, as well as the patient's ability to take the medications as intended and adhere to the regimen. This article reviews the growing body of literature demonstrating the value of comprehensive medication management in achieving the quadruple aim of health care: better care, reduced health care costs, an improved patient experience, and provider well-being.
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Affiliation(s)
- M Shawn McFarland
- National Clinical Pharmacy Practice Program Manager, Clinical Practice Integration and Model Advancement, Clinical Pharmacy Practice Office, Pharmacy Benefits Management Services, Veterans Health Administration, Washington, DC.
| | - Marcia L Buck
- Director, Clinical Practice Advancement, American College of Clinical Pharmacy, Washington, DC
| | - Erica Crannage
- Associate Professor, Department of Pharmacy Practice, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Mo
| | - Lori T Armistead
- Senior Research Associate, Clinical Coordinator, Center for Medication Optimization, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Heather Ourth
- National Program Manager for the Clinical Pharmacy Practice Program and Outcomes Assessment, Veterans Health Administration, Washington, DC
| | - Shannon W Finks
- Professor, Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, Memphis
| | - Mary Roth McClurg
- Professor and Executive Vice Dean-Chief Academic Officer, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
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Livet M, Blanchard C, Richard C, Sheppard K, Yannayon M, Sorensen T, McClurg MR. Measuring implementation of medication optimization services: Development and validation of an implementation outcomes questionnaire. Res Social Adm Pharm 2021; 17:1623-30. [PMID: 33526353 DOI: 10.1016/j.sapharm.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/23/2020] [Accepted: 01/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Implementation outcomes serve as progress and success indicators of the implementation process. They are also key antecedents to achieving the more traditional clinical outcomes typically associated with a service. Despite their importance, there are few implementation outcomes measures with appropriate psychometric properties, none of which have yet been adapted for medication optimization services. OBJECTIVES This study aims to develop and validate the Implementation Outcomes Questionnaire (IOQ) to assess implementation of medication optimization services, starting with Comprehensive Medication Management (CMM). The resulting IOQ is a 40-item self-report instrument for six implementation outcomes, including adoption, acceptability, feasibility, appropriateness, penetration, and sustainability. METHODS A three-phase approach was used to develop and validate the IOQ. Development of the instrument, Phase I, was informed by a targeted search of existing implementation outcomes measures in other fields, a review of suitableoptions options by an expert panel, and item adaptation. To assess content validity, Phase II, an internal vetting process was conducted using an adapted version of Rubio and colleagues' methodology. Evidence of reliability and construct validity, Phase III, was obtained through a pilot test with 167 pharmacists within 78 different care settings. RESULTS Overall, the results supported the reliability and validity (both content and construct) of the IOQ, with further psychometric testing needed for adoption. The items' relevance, clarity, and alignment with each implementation concept were high, except for Penetration. As a result, the Penetration items were refined for further use. Best-fit models were identified for each outcome based on the MCFA analyses, thereby providing insights into the factor structures and interpretation for each measure. Cronbach' alphas indicated good internal consistency. CONCLUSIONS This questionnaire is the first of its kind tailored to medication optimization services, starting with CMM. Access to this survey should facilitate measurement of implementation outcomes, thereby increasing the likelihood of achieving the desired clinical outcomes.
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Alenezi A, Yahyouche A, Paudyal V. Interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain: a systematic review. Eur J Clin Pharmacol 2021; 77:467-90. [PMID: 33123784 DOI: 10.1007/s00228-020-03026-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022]
Abstract
Purpose Sub-optimal opioid prescribing and use is viewed as a major contributor to the growing opioid crisis. This study aims to systematically review the nature, process and outcomes of interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain (CNMP) with a particular focus on minimizing misuse of opiates. Methods A systematic review of literature was undertaken. Search of literature using Medline, EMBASE and CINAHL databases from 2000 onwards was conducted. Screening and selection, data extraction and risk of bias assessments were undertaken by two independent reviewers. Narrative synthesis of the data was conducted. Results A total of 21 studies were included in the review, of which three were RCTs. Interventions included clinical (e.g. urine drug testing, opioid treatment contract, pill count), behavioural (e.g. electrical diaries about craving), cognitive behavioural treatment and/or educational interventions for patients and healthcare providers delivered as a single or as a multi-component intervention. Medication optimization outcomes included aspects of misuse, abuse, aberrant drug behaviour, adherence and non-adherence. Although all evaluations showed improvement in medication optimization outcomes, multi-component interventions were more likely to consider and to have shown improvement in clinical outcomes such as pain intensity, quality of life, psychological states and functional improvement compared to single-component interventions. Conclusions A well-structured CNMP management programme to promote medicines optimization should include multi-component interventions delivered by a multidisciplinary team of healthcare professionals and target both healthcare professionals and patients. There was heterogeneity in definitions applied and interventions evaluated. There is a need for the development of clear and consistent terminology and measurement criteria to facilitate better comparisons of research evidence. Supplementary Information The online version of this article (10.1007/s00228-020-03026-4) contains supplementary material, which is available to authorized users.
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Rieg S, Wehling M. FORTA(Fit-fOR-The-Aged)-based medication optimization: retrospective analysis of experiences from an unconventional outpatient service. Eur Geriatr Med 2020; 11:1035-41. [PMID: 32772258 DOI: 10.1007/s41999-020-00378-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Abstract
Aim To map prescription considerations concerning older community dwelling subjects emerging in a special gerontopharmacology hospital-based consultation. Findings Almost 10 recommendations had to be issued per patient: drugs to be stopped, added or replaced, dosing, frequency and time of intake were optimized. Applying the Fit-fOR-The-Aged (FORTA) tool resulted in a significant improvement of under- and overtreatment errors, and the sum of errors, the FORTA score. Message A medication review service aided by the FORTA tool detects a large number of medication errors in older outpatients and should be established in other places as well. Purpose To address potentially harmful polypharmacy in multimorbid older patients. Secondary to assess FORTA (Fit-fOR-The-Aged) utility in ambulatory patients. Methods Consecutive patients attending a novel ambulatory service for gerontopharmacology were included in this retrospective analysis. Baseline data, diagnoses, previous drug treatment and recommended changes in medication were analysed and the change of the FORTA score (sum of over- and undertreatment errors) calculated. Results The analysis of 182 cases revealed a high number of recommended medication alterations per case (9.81; 95% CI 9.13–10.50). The FORTA score was significantly reduced from 4.24 ± 2.30 to 0.80 ± 1.08 (P < 0.00001), as were under- and overtreatment errors if analysed separately. Conclusions The large number of recommendations given in this special outpatient service points to a profound unmet medical need for improving medications in older patients. The FORTA approach was found to be useful to reduce both over- and undertreatment in multimorbid older patients.
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Pazan F, Petrovic M, Cherubini A, Onder G, Cruz-Jentoft AJ, Denkinger M, van der Cammen TJM, Stevenson JM, Ibrahim K, Rajkumar C, Bakken MS, Baeyens JP, Crome P, Frühwald T, Gallaghar P, Guðmundsson A, Knol W, O'Mahony D, Pilotto A, Rönnemaa E, Serra-Rexach JA, Soulis G, van Marum RJ, Ziere G, Mair A, Burkhardt H, Neumann-Podczaska A, Wieczorowska-Tobis K, Fernandes MA, Gruner H, Dallmeier D, Beuscart JB, van der Velde N, Wehling M. Current evidence on the impact of medication optimization or pharmacological interventions on frailty or aspects of frailty: a systematic review of randomized controlled trials. Eur J Clin Pharmacol 2021; 77:1-12. [PMID: 32770278 DOI: 10.1007/s00228-020-02951-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/30/2020] [Indexed: 01/30/2023]
Abstract
Background Frailty and adverse drug effects are linked in the fact that polypharmacy is correlated with the severity of frailty; however, a causal relation has not been proven in older people with clinically manifest frailty. Methods A literature search was performed in Medline to detect prospective randomized controlled trials (RCTs) testing the effects of pharmacological interventions or medication optimization in older frail adults on comprehensive frailty scores or partial aspects of frailty that were published from January 1998 to October 2019. Results Twenty-five studies were identified, 4 on comprehensive frailty scores and 21 on aspects of frailty. Two trials on comprehensive frailty scores showed positive results on frailty although the contribution of medication review in a multidimensional approach was unclear. In the studies on aspects related to frailty, ten individual drug interventions showed improvement in physical performance, muscle strength or body composition utilizing alfacalcidol, teriparatide, piroxicam, testosterone, recombinant human chorionic gonadotropin, or capromorelin. There were no studies examining negative effects of drugs on frailty. Conclusion So far, data on a causal relationship between drugs and frailty are inconclusive or related to single-drug interventions on partial aspects of frailty. There is a clear need for RCTs on this topic that should be based on a comprehensive, internationally consistent and thus reproducible concept of frailty assessment. Electronic supplementary material The online version of this article (10.1007/s00228-020-02951-8) contains supplementary material, which is available to authorized users.
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Tripicchio K, Urick B, Easter J, Ozawa S. Making the economic value proposition for pharmacist comprehensive medication management (CMM) in primary care: A conceptual framework. Res Social Adm Pharm 2020; 16:1416-1421. [PMID: 31918964 DOI: 10.1016/j.sapharm.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/15/2019] [Accepted: 01/01/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Comprehensive medication management (CMM) is a patient care process provided by clinical pharmacists in primary care settings that ensures optimal use of medications with timely follow-up. Despite widespread evidence that shows CMM improves clinical and medication-related outcomes, pharmacist-delivered CMM services often fail to be adopted into U.S. primary care settings. OBJECTIVE This study presents a conceptual framework linking outcomes of pharmacist-delivered CMM services in primary care settings to financial benefits for health plans providing coverage of CMM services and primary care practices investing and implementing CMM. METHODS A critical review of the literature was performed in PubMed and the gray literature to identify financing opportunities that justify the coverage of CMM by third-party health plan administrators or the implementation of CMM by primary care practices. Financing elements that could be impacted by pharmacist-led CMM outcomes, namely higher achievement of medication-related quality measures and reduction of total costs of care, were recorded and utilized to develop the conceptual framework. RESULTS The framework suggests that CMM provides economic benefits to both health plans and primary care practices by increasing market competitiveness, direct revenue, and quality bonuses. Health plans may benefit from higher plan quality ratings, lower premiums and plan bids, increased shared savings, and quality bonus payments. Primary care practices may achieve increased negotiating power through accreditation recognition and patient satisfaction, increased revenue through shared savings and fee-for-service reimbursement, and achievement of quality bonus payments. CONCLUSIONS The alignment of economic benefits from CMM advances a strong value proposition for greater adoption of CMM coverage by health plans and implementation in the U.S. primary care system. Through broader CMM implementation, pharmacists can work alongside physicians in advanced care models and play a vital role in shaping the primary care practice transition to value-based care.
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Affiliation(s)
- Kristen Tripicchio
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
| | - Benjamin Urick
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Jon Easter
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA; Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
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Abstract
Pharmacogenomics (PGx) is a powerful tool that can predict increased risks of adverse effects and sub-therapeutic response to medications. This article establishes the core principles necessary for a primary care provider to meaningfully and prudently use PGx testing. Key topics include in which patients PGx testing should be considered, how PGx tests are ordered, how the results are translated into clinical recommendations, and what further advancements are likely in the near future. This will provide clinicians with a foundational knowledge of PGx that can allow incorporation of this tool into their practice or support further personal investigation.
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Affiliation(s)
- Dyson T Wake
- Pharmacogenomics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Nadim Ilbawi
- Department of Family Medicine, NorthShore University HealthSystem, 6810 North McCormick Boulevard, Lincolnwood, IL 60712, USA
| | - Henry Mark Dunnenberger
- Pharmacogenomics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Peter J Hulick
- Center for Medical Genetics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, 1000 Central Street Suite 610, Evanston, IL 60201, USA.
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Pazan F, Burkhardt H, Frohnhofen H, Weiss C, Throm C, Kuhn-Thiel A, Wehling M. Changes in prescription patterns in older hospitalized patients: the impact of FORTA on disease-related over- and under-treatments. Eur J Clin Pharmacol 2017; 74:339-347. [PMID: 29196825 DOI: 10.1007/s00228-017-2383-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 07/20/2017] [Accepted: 11/16/2017] [Indexed: 01/28/2023]
Abstract
PURPOSE Physicians often face difficulties in choosing appropriate medications for multimorbid older people. The FORTA (Fit for the Aged) classification (A: absolutely, B: beneficial, C: careful, D: don't) was proposed as a clinical tool for improving the quality of drug treatment in the aged. As an implicit tool, FORTA has been shown to aid medication optimization and improve clinical end points in the VALFORTA trial. In this prospective randomized controlled study, 207 older hospitalized patients received standard geriatric treatment and 202 patients received FORTA-guided treatment. METHODS Here, changes of drug prescriptions at the anatomical-therapeutic-chemical system (ATC) level were evaluated separately for important diagnoses in descriptive analyses; over- and under-treatment rates were compared between groups. RESULTS At the individual drug/drug class level related to all important diagnoses, the application of FORTA significantly improved under-treatments for 12 drugs/drug classes (e.g., ACE inhibitors to treat arterial hypertension) and over-treatments for 7 drugs/drug classes (e.g., proton pump inhibitors to treat gastroesophageal reflux disease). CONCLUSIONS FORTA representing the first combined positive/negative labeling approach at the individual drug level aids the optimization of drug treatment in older people as detected for drugs/drug classes at the ATC level in important indications. FORTA is effective in addressing over- and under-treatments even if analyzed for smaller subgroups of VALFORTA.
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Affiliation(s)
- Farhad Pazan
- Institute for Experimental and Clinical Pharmacology and Toxicology, Clinical Pharmacology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Heinrich Burkhardt
- IV. Medical Department, Geriatrics, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Helmut Frohnhofen
- Faculty of Health, Department of Medicine, University Witten-Herdecke, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Str. 13-16, 68167, Mannheim, Germany
| | - Christina Throm
- Department of Cardiology and Angiology, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, 60431, Frankfurt, Germany
| | | | - Martin Wehling
- Institute for Experimental and Clinical Pharmacology and Toxicology, Clinical Pharmacology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Singh S, Bajorek B. Pharmacotherapy in the ageing patient: The impact of age per se (A review). Ageing Res Rev 2015; 24:99-110. [PMID: 26226330 DOI: 10.1016/j.arr.2015.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/17/2015] [Indexed: 12/23/2022]
Abstract
A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.
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