Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study

Background

Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians’ baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians’ (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios.

Methods

As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients’ expectations surrounding low-value prescribing.

Results

We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients’ well-being over satisfying their expectations.

Conclusions

When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults

IMPORTANCE

Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing.

OBJECTIVE

To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021.

MAIN OUTCOMES AND MEASURES

Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method.

RESULTS

Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5).

CONCLUSIONS AND RELEVANCE

This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.

Prescriber perspectives on low-value prescribing: A qualitative study

BACKGROUND

Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood.

OBJECTIVE

To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians.

DESIGN

Qualitative study using semi-structured interviews.

SETTING

Academic and community primary care practices within University of Pittsburgh Medical Center health system.

PARTICIPANTS

Sixteen primary care physicians.

MEASUREMENTS

We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing.

RESULTS

We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable.

CONCLUSIONS

Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

0138 Behaviorally Assessed Sleep Duration and Oxidative Stress

Introduction

Sleep may promote health by acting as an antioxidant, thereby increasing the body’s resistance to oxidative stress. Lipid peroxidation, a marker of oxidative stress, is one of the key early events in the development of atherosclerosis, the pathologic condition that underlies cardiovascular disease (CVD). Short sleep duration is prevalent in the general population and associated with CVD risk. However, the mechanisms linking short sleep to CVD are not well understood.

Methods

To test the hypothesis that short sleep duration would be associated with higher levels of oxidative stress, we conducted secondary data analysis on a diverse sample of participants (N= 81; Mage = 30.1(SD=10.9); 57% Male; 27% African American) from Pittsburgh, Pennsylvania. Participants wore actigraphs on their non-dominant wrists for 7 days to collect rest and activity data, which were used to derive average sleep duration. Participants provided urine samples and self-reported demographic data, along with daily mood, alcohol use, and physical activity. Oxidative stress was quantified as urinary concentrations of 15-F2t-isoprostane (15-F2-IsoP). Levels of 15-F2-IsoP were measured with a competitive enzyme linked-immunosorbent assay (ELISA) in duplicate. Urinary 15-F2-IsoP was adjusted by urinary creatinine to create an index of oxidative stress that took into account a measure of antioxidant defenses.

Results

Sleep duration was inversely correlated with oxidative stress (b= -.24, p=.03). In multiple regression analyses that controlled for age, sex, race, body mass index, alcohol use, physical activity, and depressed mood, sleep duration remained significantly negatively associated with oxidative stress, β = -.16, t = -2.33, p = .02, R2= .20.

Conclusion

These findings are important because they suggest that a relationship exists between short sleep and increased oxidative damage to lipids. Increasing our understanding of this relationship could motivate new CVD prevention strategies that target the inhibition of oxidative stress through sleep interventions.

Support

This study was supported by a grant from the National Center for Complementary and Integrative Health (AT006694); a grant from the National Institute of Allergy and Infectious Diseases (R01 AI066367); grants from the National Institutes of Health (UL1 RR024153 and UL1 RT000005); and by the John D. and Catherine T. MacArthur Foundation.

[New protocol combining orthodontics and implant therapy for partially edentulous adult patients. Part I: Description of the Decker protocol]

INTRODUCTION

The treatment of adult malocclusion is usually complex and pluridisciplinary. Its prognosis is not reliable. We present a new clinical protocol to improve the management and final result.

TECHNICAL NOTE

We use a specific software (Simplant®, OMS®, Materialise Dental) and its accessory modules. It allows visualization of the expected final clinical result of the orthodontic treatment. Combined with guided-surgery, it allows placing implants at the beginning of treatment in a position that is compatible with the final position. The implants serve as absolute anchorage for dental motions during the orthodontic step; it is also used to support the final prosthesis. The treatment is thus optimized and its prognosis is improved. Finally, the reversed surgical sequences shorten the treatment thus promoting the compliance of patients.

Verhaltenssymptome bei Demenz in Pflegeeinrichtungen

In fortgeschrittenen Stadien von Demenzerkrankungen treten neben Depression vermehrt Verhaltenssymptome auf, zu denen Unruhe, Aggressivität und Halluzinationen zählen. In Pflegeeinrichtungen betrifft dies bis zu drei Viertel aller Bewohner. Diese Symptome sind für Pflegende belastend, ziehen erhöhte Versorgungskosten, eine vermehrte Verschreibung von Psychopharmaka, sowie häufigere Krankenhausaufenthalte nach sich. Im Jahr 2003 haben die Amerikanischen Gesellschaften für Gerontopsychiatrie und Geriatrie Leitlinien zur Behandlung von Depressionen und Verhaltenssymptomen in Pflegeeinrichtungen vorgestellt. Vergleichbare Leitlinien der deutschen Fachgesellschaften liegen bislang nicht vor. Die amerikanischen Leitlinien geben neben einem standardisierten Assessment Therapiealgorhythmen vor. In unserem Projekt werden diese Leitlinien in acht Pflegeinrichtungen in Berlin eingeführt und die Ausprägung von Verhaltenssymptomen, die Verschreibung von Psychopharmaka, die Anzahl der Krankenhauseinweisungen und die Belastung der Pflegenden mit einer Kontrollstichprobe von acht vergleichbaren Pflegeeinrichtungen ohne Leitlinienbehandlung über einen Zeitraum von 12 Monaten verglichen. Wir erwarten eine Verminderung der Ausprägung von Verhaltenssymptomen, sowie der Psychopharmakaverschreibungen, der Hospitalisierungsrate und der subjektiven Belastung für Pflegende.

Method Modification (2004.08) to Field Testing of Visible Powders on a Variety of Nonporous Environmental Surfaces: Field Study

The RAMP® Anthrax Test Cartridge for detecting Bacillus anthracis was validated for use in the field for detection of B. anthracis spores in visible powder residues on 7 nonporous environmental surfaces. Six teams of trained first responders and civil support personnel in Class C personal protective equipment sampled visible powder residues on plastic, stainless steel, ceramic tile, wood, rubber, sealed concrete, and food-grade painted wood and analyzed the samples on the RAMP Anthrax Test System. The accuracy for each surface was at least 97% and the overall average was 98.8%. The overall average false-positive rate was 1.79% and false-negative rate was 1.07% for all surfaces. There were no significant differences between surfaces or between spore levels.

Microarray-based analysis of gene expression in very large gene families: the cytochrome P450 gene superfamily of Arabidopsis thaliana

Cytochrome P450 (P450s) are heme-thiolate protein products of a very large gene superfamily, present in all kingdoms and involved in a variety of metabolic reactions. P450s are classified according to the degree of amino acid sequence identity, with P450s of the same family defined as having >40% identity, and P450s of the same subfamily having >55% identity. Currently, 273 P450 genes distributed over 45 families have been identified in Arabidopsis, and its genome is estimated to contain as many as 286. Genome-wide DNA microarrays make it possible to broadly correlate P450 gene activity with alterations in physiological or developmental states. A potential problem with microarray research is that sequence similarity between and within these families of closely related genes may lead to cross-hybridization. We designed experiments to systematically evaluate the specificity of P450 microarrays, and showed that conditions could be optimized to provide a very high degree of hybridization specificity. Under these conditions, and employing a 20% intensity value of maximum hybridization intensity as a cut-off, labeled P450 genes exhibited essentially no cross-hybridization between families and within subfamilies. We also compared the gene transcription levels of microarray probes derived from EST clones and from genomic DNA sequences for which ESTs were not available, using cDNA produced from RNA from various Arabidopsis tissue as the target. Many of the P450 genes displayed tissue-specific expression, leading to hypotheses as to the function of individual genes and their regulation. We also observed that several of the genomic sequences reported high levels of expression, highlighting the limitations of expression analysis based on ESTs alone.

[Mechanics of palatal expansion in the occlusal plane]

The mechanics of a transpalatal arch in the occlusal plane (symmetrical V-bends, asymmetrical V-bends and step-bends) is studied through four methods: simulation of the teeth movements with a typodont, measure of the forces and the moments with a mechanical system composed of pulleys and dead load devices, photo-elastic stress analysis, finite element stress analysis. Typodont experimentations display the dental movements: the easiest one is rotation; it is more difficult to observe distalization and mesialisation that occur with a version of the tooth. An experimental apparatus, composed of pulleys and dead load devices, allows to measure forces and moments released by a transpalatal arch, depending on the level of the activations. The authors notice that the distalization force for an asymmetrical V-bend activation is low, about 0.2 Newton for 5 degrees of activation. Photo-elastic stress analysis affords a visualization of the shear stresses induced by a transpalatal arch within the supporting structures of a root, thanks to the observation of colored fringes in a model constituted with two molars included in a birefringent resin. Meanwhile, the manipulation of the photo-elastic resin is not easy and the interpretation of the results remains difficult. The finite element method is a numerical analysis and consists in the fragmentation of the studied structure in a certain number of elements, where forces and moments can be applied: the three dimensional program analyses the stress and strains in these elements. Thus, we can: 1.--visualize strains and stresses of a transpalatal arch, when it is inserted in the lingual molar sheaths; 2.--observe the dental movements due to the activations of the transpalatal arch (rotation, version, mesialisation, distalization); 3.--study the stress induced in the periodontal tissue. The results of these studies are complementary and in agreement. Particularly, the second method (measure of forces and moments) and the finite element method provide a mathematical and visual model that could explain clinical results: thus, the main purpose of this research is to understand the orthodontic mechanics used in the edgewise or segmented technique.

Pressor and depressor responses in thermocoagulation of the trigeminal ganglion

We have undertaken a retrospective analysis in 126 patients with trigeminal neuralgia on which a free-hand percutaneous thermocoagulation of the Gasserian ganglion was performed in our department. We focused on the occurrence of intraoperative vagal reactions, i.e. significant bradycardia and changes in blood pressure during the course of the procedure. Operative and anaesthetic records of patients who underwent the procedure were evaluated and correlated with clinical data from the patient's history. We observed the occurrence of vagal reactions i.e. significant bradycardia (< 50/min) or syncope in 20% of patients (p < 0.0002) during or immediately after penetration of the foramen ovale. No correlation between the operated side and the occurrence of vagal reactions was found. A significant rise in blood pressure levels (about 180 mmHg systolic) was observed in 36% of patients during thermocoagulation. We concluded that painful stimuli arising from lesioning in the course of the trigeminal nerve reach the mid-brain and may irritate the dorsal nucleus of the vagus nerve resulting in significant bradycardia or cardiac synode. To prevent haemodynamic deterioration i.v. atropine (0.5-2 mg) should be available when advancing the needle, while anti-hypertensive medication (Esmolol) may be needed during coagulation.

MRI abnormalities in Creutzfeldt-Jakob disease

Two patients with biopsy-proven Creutzfeldt-Jakob disease had MRI studies that revealed increased signal in the basal ganglia on T-2 weighted images, suggesting that MRI can be a useful diagnostic instrument in Creutzfeldt-Jakob disease.

Phase I-II trial of aclacinomycin A given in a four-consecutive-day schedule to patients with solid tumours. A South-East European Oncology Group (SEEOG) Study

Aclacinomycin A (ACM) in a daily dose of 30 mg/m2 was infused over 1 h on 4 consecutive days to 50 patients. Myelotoxicity was acceptable, nausea and vomiting was frequent, hair loss was mild. Grade 1-2 cardiac rhythm abnormalities were observed in 12% of the patients. Between days 1 and 4 the heart rate and the corrected Q-T interval increased while the amplitude of the T wave decreased significantly, cardiac contractility remained unchanged. In 24 evaluable breast cancer patients 1 complete remission (4%) and 2 partial remissions (8%) lasting for only 2-3 months were seen. None of the 8 patients suffering from ovarial cancer benefitted from ACM therapy.