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Tyler N, Hodkinson A, Planner C, Angelakis I, Keyworth C, Hall A, Jones PP, Wright OG, Keers R, Blakeman T, Panagioti M. Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2023; 6:e2344825. [PMID: 38032642 PMCID: PMC10690480 DOI: 10.1001/jamanetworkopen.2023.44825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Discharge from the hospital to the community has been associated with serious patient risks and excess service costs. Objective To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community. Data Sources CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022. Study Selection Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified. Data Extraction and Synthesis At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Main Outcomes and Measures The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake. Results Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits. Conclusions and Relevance These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.
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Affiliation(s)
- Natasha Tyler
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Claire Planner
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Ioannis Angelakis
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- Institute of Population Health, Department of Primary Care & Mental Health, University of Liverpool, Liverpool, United Kingdom
| | | | - Alex Hall
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | | | | | - Richard Keers
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
- Pharmacy Department, Pennine Care NHS Foundation Trust, Aston-Under-Lyne, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Tom Blakeman
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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Babu D, Rowett D, Lim R, Marotti S, Wisdom A, Ellett LK. Clinical pharmacists' participation in ward rounds in hospitals: responses from a national survey. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023:7161614. [PMID: 37178018 DOI: 10.1093/ijpp/riad028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES The inclusion of clinical pharmacists in ward rounds (WRs) can reduce adverse drug events, improve communication and enable collaborative decision-making. The aim of this study is to investigate the level of and factors that influence WR participation by clinical pharmacists in Australia. METHODS An online administered, anonymous survey of clinical pharmacists in Australia was conducted. The survey was open to pharmacists aged ≥18 years, who had worked in an Australian hospital in a clinical role in the previous two weeks. It was distributed via The Society of Hospital Pharmacists of Australia and on pharmacist-specific social media threads. Survey questions related to the extent of WR participation and factors that influence WR participation. Cross-tabulation analysis was conducted to determine whether there was an association between WR participation and factors that influence WR participation. KEY FINDINGS Ninety-nine responses were included. The level of WR participation by clinical pharmacists in Australian hospitals was low, with only 26/67 (39%) pharmacists who had a WR in their clinical unit actually attending the WR in the previous 2 weeks. Factors that influenced WR participation included having recognition of the role of the clinical pharmacist within the WR team, support from pharmacy management and the broader interprofessional team, and having adequate time and expectation from pharmacy management and colleagues to participate in WRs. CONCLUSIONS This study highlights the need for ongoing interventions such as restructuring workflows and increasing the awareness of the role of a clinical pharmacist in WR to increase participation of pharmacists in this interprofessional activity.
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Affiliation(s)
- Dona Babu
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- SA Pharmacy, SA Health, Adelaide, SA, Australia
| | - Debra Rowett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- SA Pharmacy, SA Health, Adelaide, SA, Australia
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Sally Marotti
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- SA Pharmacy, SA Health, Adelaide, SA, Australia
| | | | - Lisa Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Kripalani S, Mixon AS, Simmons SF. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023; 183:223-231. [PMID: 36745422 PMCID: PMC9989899 DOI: 10.1001/jamainternmed.2022.6545] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. Objective To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. Design, Setting, and Participants This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. Interventions The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. Main Outcomes and Measures The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. Results A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Conclusions and Relevance Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02979353.
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Affiliation(s)
- Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Sunil Kripalani
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S. Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Bayliss EA, Albers K, Gleason K, Pieper LE, Boyd CM, Campbell NL, Ensrud KE, Gray SL, Linsky AM, Mangin D, Min L, Rich MW, Steinman MA, Turner J, Vasilevskis EE, Dublin S. Recommendations for outcome measurement for deprescribing intervention studies. J Am Geriatr Soc 2022; 70:2487-2497. [PMID: 35648465 PMCID: PMC9489620 DOI: 10.1111/jgs.17894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/21/2022] [Accepted: 05/03/2022] [Indexed: 01/03/2023]
Abstract
Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.
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Affiliation(s)
- Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathleen Albers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Lisa E Pieper
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Kristine E Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Care Delivery and Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Amy M Linsky
- Section of General Internal Medicine and Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Derelie Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Lillian Min
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Ann Arbor VA Medical Center, Geriatric Education Research and Clinical Center, Ann Arbor, Michigan, USA
| | - Michael W Rich
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatraics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Justin Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Epidemiology Department, University of Washington, Seattle, Washington, USA
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Desai M, Park T. Deprescribing practices in Canada: A scoping review. Can Pharm J (Ott) 2022; 155:249-257. [PMID: 36081917 PMCID: PMC9445505 DOI: 10.1177/17151635221114114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Background: Excessive and inappropriate use of medications, defined as polypharmacy, can increase the risk of adverse drug reactions while affecting patient adherence and quality of life. Therefore, optimizing pharmacotherapies through deprescribing practices plays a crucial role in managing chronic conditions, avoiding adverse effects and improving patient outcomes. The purpose of this study was to explore research initiatives surrounding deprescribing in Canada. Methods: A scoping review was conducted that involved a search of 6 databases. Studies that highlighted deprescribing interventions, experiences and other effects on Canadian populations were included. Results: Searches yielded 2327 citations, of which 31 were included in this review. Five major themes and ideas were identified: deprescribing targeted medications, financial effects of deprescribing, deprescribing in special populations, insight from health care providers and deprescribing frameworks. Conclusion: Deprescribing practices in Canada have shown a wide range of beneficial results across various health care settings, populations and medication classes and have the potential to reduce medication-related harm in all Canadian health care settings.
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Rana R, Choi J, Vordenberg SE. Older adults’ willingness to consider deprescribing when experiencing hyperpolypharmacy. J Am Pharm Assoc (2003) 2022; 62:1189-1196. [DOI: 10.1016/j.japh.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
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Abstract
Clinicians are responsible for both commencing and stopping medications. This study evaluates the attitudes of older acute medical inpatients about deprescribing. Overall, patients are positive toward stopping medications, want to be involved and do not feel a clinician is giving up on them if a medication is stopped. Patients on fewer medications counterintuitively feel a greater medication burden, are more interested in being involved in decision making and consider deprescribing appropriate to a greater degree than patients who are taking more medications. Conversely, they also reported greater concerns about stopping medications. We discuss these findings in the context of the positive and negative effects of deprescribing, in the context of patient engagement and shared decision making, and how clinicians can work with inpatients to reduce potentially inappropriate medications.
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Feasibility & Efficacy of Deprescribing rounds in a Singapore rehabilitative hospital- a randomised controlled trial. BMC Geriatr 2021; 21:584. [PMID: 34674645 PMCID: PMC8529728 DOI: 10.1186/s12877-021-02507-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 09/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background Deprescribing is effective and safe in reducing polypharmacy among the elderly. However, the impact of deprescribing rounds remain unclear in Asian settings. Hence, we conducted this study. Methods An open label randomised controlled trial was conducted on patients of 65 years and above, under rehabilitation or subacute care and with prespecified medications from a Singapore rehabilitation hospital. They were randomised using a computer generated sequence. The intervention consisted of weekly multidisciplinary team-led deprescribing rounds (using five steps of deprescribing) and usual care. The control had only usual care. The primary outcome is the percentage change in total daily dose (TDD) from baseline upon discharge, while the secondary outcomes are the total number of medicine, total daily cost and TDD up to day 28 postdischarge, overall side-effect rates, rounding time and the challenges. Efficacy outcomes were analysed using intention-to-treat while other outcomes were analysed as per protocol. Results 260 patients were randomised and 253 were analysed after excluding dropouts (female: 57.3%; median age: 76 years). Baseline characteristics were largely similar in both groups. The intervention arm (n = 126) experienced a greater reduction of TDD on discharge [Median (IQR): − 19.62% (− 34.38, 0.00%) versus 0.00% (− 12.00, 6.82%); p < 0.001], more constipation (OR: 3.75, 95% CI:1.75–8.06, p < 0.001) and laxative re-prescriptions (OR: 2.82, 95% CI:1.30–6.12, p = 0.009) though death and hospitalisation rates were similar. The median rounding time was 7.09 min per patient and challenges include the inconvenience in assembling the multidisciplinary team. Conclusion Deprescribing rounds can safely reduce TDD of medicine upon discharge compared to usual care in a Singaporean rehabilitation hospital. Trial registration This study is first registered at Clinicaltrials.gov (protocol number: NCT03713112) on 19/10/2018 and the protocol can be accessed on https://www.clinicaltrials.gov. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02507-0.
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Whitman A, Erdeljac P, Jones C, Pillarella N, Nightingale G. Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings. DRUG HEALTHCARE AND PATIENT SAFETY 2021; 13:101-116. [PMID: 33953612 PMCID: PMC8092848 DOI: 10.2147/dhps.s255893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022]
Abstract
The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Paige Erdeljac
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Nicole Pillarella
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
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Ye S, Boyko S, Patel M, Shah K, Turbow S, Ohuabunwa U. Deprescribing Medications Among Older People to Reduce Polypharmacy at a Comprehensive Academic Medical Center. Sr Care Pharm 2021; 36:208-216. [PMID: 33766193 DOI: 10.4140/tcp.n.2021.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate deprescribing of select high-risk medications (HRMs) in an Acute Care for the Elderly (ACE) unit with pharmacist involvement compared with usual care in older people. DESIGN Retrospective, single-center case-control study. SETTING Medical-surgical units at an urban academic medical center. PARTICIPANTS Patients 65 years of age and older admitted April-June 2019, with 1 or more of the following target HRMs prior to admission were included in the study: acid suppressants, antipsychotics, or insulin. Patients admitted to the ACE unit were included in the case group; all other patients were randomly matched by HRMs in a 2:1 ratio into the control group. INTERVENTIONS The Acute Care for the Elderly pharmacist reviewed patients' medications to identify and deprescribe select HRMs. Deprescribing was defined as discontinuation, dose or frequency reduction. RESULTS A total of 47 patients with 56 HRMs and 89 patients with 126 HRMs were included in the case and control groups, respectively. The primary outcome of HRMs deprescribed were similar between the case and control groups (21.4% and 25.4%; P = 0.56). Among the HRMs deprescribed (discontinued, dose or frequency reduced), 83.2% were complete discontinuations in case patients and 34.4% were complete discontinuations in control patients.
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Affiliation(s)
- Stella Ye
- 1Grady Health System, Department of Pharmacy and Drug Information, Atlanta, Georgia
| | - Sarah Boyko
- 1Grady Health System, Department of Pharmacy and Drug Information, Atlanta, Georgia
| | - Melissa Patel
- 1Grady Health System, Department of Pharmacy and Drug Information, Atlanta, Georgia
| | - Kruti Shah
- 1Grady Health System, Department of Pharmacy and Drug Information, Atlanta, Georgia
| | - Sara Turbow
- 2Emory University School of Medicine, Division of General Medicine and Geriatrics, Division of Preventive Medicine, Atlanta, Georgia
| | - Ugochi Ohuabunwa
- 2Emory University School of Medicine, Division of General Medicine and Geriatrics, Division of Preventive Medicine, Atlanta, Georgia
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12
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Dautzenberg L, Bretagne L, Koek HL, Tsokani S, Zevgiti S, Rodondi N, Scholten RJPM, Rutjes AW, Di Nisio M, Raijmann RCMA, Emmelot-Vonk M, Jennings ELM, Dalleur O, Mavridis D, Knol W. Medication review interventions to reduce hospital readmissions in older people. J Am Geriatr Soc 2021; 69:1646-1658. [PMID: 33576506 PMCID: PMC8247962 DOI: 10.1111/jgs.17041] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective To assess the efficacy of medication review as an isolated intervention and with several co‐interventions for preventing hospital readmissions in older adults. Methods Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co‐interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were “at least one all‐cause hospital readmission within 30 days and at any time after discharge from the index admission.” Results Twenty‐five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta‐analysis (NMA) on all‐cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26–0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49–0.84) were associated with a lower risk of all‐cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45–2.51). The NMA on all‐cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74–0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination. Conclusion Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co‐interventions was not demonstrated. Trials of higher quality are needed in this field.
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Affiliation(s)
- Lauren Dautzenberg
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lisa Bretagne
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Huiberdina L Koek
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sofia Tsokani
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Stella Zevgiti
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Rob J P M Scholten
- Cochrane Netherlands/Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne W Rutjes
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti, Italy
| | - Renee C M A Raijmann
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marielle Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emma L M Jennings
- School of Medicine, University College Cork, National University of Ireland, Cork, Ireland.,Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
| | - Olivia Dalleur
- Louvain Drug Research Institute (LDRI), Clinical Pharmacy Research Group, Université catholique de Louvain-UCLouvain, Brussels, Belgium.,Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain-UCLouvain, Brussels, Belgium
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.,Sorbonne Paris Cité, Faculté de Médecine, Paris Descartes University, Paris, France
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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13
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Lorman-Carbó B, Clua-Espuny JL, Muria-Subirats E, Ballesta-Ors J, González-Henares MA, Fernández-Sáez J, Martín-Luján FM. Complex chronic patients as an emergent group with high risk of intracerebral haemorrhage: an observational cohort study. BMC Geriatr 2021; 21:106. [PMID: 33546615 PMCID: PMC7863444 DOI: 10.1186/s12877-021-02004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background Demographic aging is a generalised event and the proportion of older adults is increasing rapidly worldwide with chronic pathologies, disability, and complexity of health needs. The intracerebral haemorrhage (ICH) has devastating consequences in high risk people. This study aims to quantify the incidence of ICH in complex chronic patients (CCP). Methods This is a multicentre, retrospective and community-based cohort study of 3594 CCPs followed up from 01/01/2013 to 31/12/2017 in primary care without a history of previous ICH episode. The cases were identified from clinical records encoded with ICD-10 (10th version of the International Classification of Diseases) in the e-SAP database of the Catalan Health Institute. The main variable was the ICH episode during the study period. Demographic, clinical, functional, cognitive and pharmacological variables were included. Descriptive and logistic regression analyses were carried out to identify the variables associated with suffering an ICH. The independent risk factors were obtained from logistic regression models, ruling out the variables included in the HAS-BLED score, to avoid duplication effects. Results are presented as odds ratio (OR) and 95% confidence interval (CI). The analysis with the resulting model was also stratified by sex. Results 161 (4.4%) participants suffered an ICH episode. Mean age 87 ± 9 years; 55.9% women. The ICH incidence density was 151/10000 person-years [95%CI 127–174], without differences by sex. Related to subjects without ICH, presented a higher prevalence of arterial hypertension (83.2% vs. 74.9%; p = 0.02), hypercholesterolemia (55.3% vs. 47.4%, p = 0.05), cardiovascular disease (36.6% vs. 28.9%; p = 0.03), and use of antiplatelet drugs (64.0% vs. 52.9%; p = 0.006). 93.2% had a HAS-BLED score ≥ 3. The independent risk factors for ICH were identified: HAS-BLED ≥3 [OR 3.54; 95%CI 1.88–6.68], hypercholesterolemia [OR 1.62; 95%CI 1.11–2.35], and cardiovascular disease [OR 1.48 IC95% 1.05–2.09]. The HAS_BLED ≥3 score showed a high sensitivity [0.93 CI95% 0.89–0.97] and negative predictive value [0.98 (CI95% 0.83–1.12)]. Conclusions In the CCP subgroup the incidence density of ICH was 5–60 times higher than that observed in elder and general population. The use of bleeding risk score as the HAS-BLED scale could improve the preventive approach of those with higher risk of ICH. Trial registration This study was retrospectively registered in ClinicalTrials.gov (NCT03247049) on August 11/2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02004-4.
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Affiliation(s)
- Blanca Lorman-Carbó
- Department of Primary Care, Catalonian Health Institute, EAP Tortosa-est, UUDD Terres de l'Ebre; University Rovira Virgili, Tortosa, Spain
| | - Josep Lluís Clua-Espuny
- Department of Primary Care, Catalonian Health Institute, University Rovira i Virgili, CAP El Temple, Plaça Carrilet s/n. 43500, Tortosa, Catalunya, Spain.
| | | | - Juan Ballesta-Ors
- Department of Primary Care, Catalonian Health Institute, EAP Tortosa-est, UUDD Terres de l'Ebre, Tortosa, Spain
| | - Maria Antònia González-Henares
- Department of Primary Care, Catalonian Health Institute, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), EAP Alcanar-Sant Carles de la Ràpita, Spain
| | - José Fernández-Sáez
- Unitat de Suport a la Recerca Terres de l'Ebre, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Spain
| | - Francisco M Martín-Luján
- Department of Primary Care, Catalonian Health Institute; Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol); University Rovira i Virgili, Reus, Spain
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14
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Vest TA, Gazda NP, Schenkat DH, Eckel SF. Practice-enhancing publications about the medication-use process in 2019. Am J Health Syst Pharm 2021; 78:141-153. [PMID: 33119100 DOI: 10.1093/ajhp/zxaa355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change. SUMMARY A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.
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Affiliation(s)
- Tyler A Vest
- Duke University Hospital, Durham, NC.,University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC
| | | | | | - Stephen F Eckel
- University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC.,University of North Carolina Medical Center, Chapel Hill, NC
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15
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Should Hospital Admission Be Used as an Opportunity for Deprescribing in Older Adults? Can J Hosp Pharm 2020; 73:294-297. [PMID: 33100363 PMCID: PMC7556391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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16
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Deprescribing in geriatric inpatients is associated with a lower readmission risk: a case control study. Int J Clin Pharm 2020; 42:1374-1378. [PMID: 32803558 DOI: 10.1007/s11096-020-01091-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
Background Polypharmacy is prevalent in older adults and has been associated with iatrogenic harm. Deprescribing has been promoted to reduce polypharmacy. It remains however unclear whether deprescribing during hospital stay can reduce the readmission risk. Objective We sought to determine whether deprescribing in geriatric inpatients was associated with a lower readmission risk at three months post-discharge. Method A case control study was performed, using data from a prospective, controlled study in geriatric inpatients. Deprescribing was defined as the percentage of discontinued preadmission medications and was assessed upon discharge. A logistic regression analysis was used to determine the odds ratio for deprescribing and the outcome of readmissions. An adjusted odds ratio was then estimated, taking into account age, sex, mortality, the number of preadmission medications and the Charlson Comorbidity Index. Results Data of 166 patients were analysed, of whom 61 had experienced at least one readmission. Adjusting for age, number of preadmission medications and mortality resulted in the most informative regression model, based on the lowest Akaike information criterion (adjusted odds ratio 0.981, 95% confidence interval 0.964 to 0.998). Conclusion Deprescribing in geriatric inpatients was associated with a reduced readmission risk at three months post-discharge.Trial registration S53664.
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17
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Akgün KM, Krishnan S, Feder SL, Tate J, Kutner JS, Crothers K. Polypharmacy Increases Risk of Dyspnea Among Adults With Serious, Life-Limiting Diseases. Am J Hosp Palliat Care 2019; 37:278-285. [PMID: 31550901 DOI: 10.1177/1049909119877512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Polypharmacy is associated with dyspnea in cross-sectional studies, but associations have not been determined in longitudinal analyses. Statins are commonly prescribed but their contribution to dyspnea is unknown. We determined whether polypharmacy was associated with dyspnea trajectory over time in adults with advanced illness enrolled in a statin discontinuation trial, overall, and in models stratified by statin discontinuation. METHODS Using data from a parallel-group unblinded pragmatic clinical trial (patients on statins ≥3 months with life expectancy of 1 month to 1 year, enrolled in the parent study between June 3, 2011, and May 2, 2013, n = 308/381 [81%]), we restricted analyses to patients with available baseline medication count and ≥1 dyspnea score. Polypharmacy was assessed by self-reported chronic medication count. Dyspnea trajectory group, our primary outcome, was determined over 24 weeks using the Edmonton Symptom Assessment System. RESULTS The mean age of the patients was 73.8 years (standard deviation [SD]: ±11.0) and the mean medication count was 11.6 (SD: ±5.0). We identified 3 dyspnea trajectory groups: none (n = 108), mild (n = 130), and moderate-severe (n = 70). Statins were discontinued in 51.8%, 48.5%, and 42.9% of patients, respectively. In multivariable models adjusting for age, sex, diagnosis, and statin discontinuation, each additional medication was associated with 8% (odds ratio [OR] = 1.08 [1.01-1.14]) and 16% (OR = 1.16 [1.08-1.25]) increased risk for mild and moderate-severe dyspnea, respectively. In stratified models, polypharmacy was associated with dyspnea in the statin continuation group only (mild OR = 1.12 [1.01-1.24], moderate-severe OR = 1.24 [1.11-1.39]) versus statin discontinuation (mild OR = 1.03 [0.95-1.12], and moderate-severe OR = 1.09 [0.98-1.22]). CONCLUSION Polypharmacy was strongly associated with dyspnea. Prospective interventions to decrease polypharmacy may impact dyspnea symptoms, especially for statins.
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Affiliation(s)
- Kathleen M Akgün
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Supriya Krishnan
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Janet Tate
- Department of Internal Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kristina Crothers
- Department of Medicine, VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA, USA
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