1
|
Warmoth K, Rees J, Day J, Cockcroft E, Aylward A, Pollock L, Coxon G, Craig T, Walton B, Stein K. Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff. Res Social Adm Pharm 2024; 20:379-388. [PMID: 38245383 DOI: 10.1016/j.sapharm.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Care home residents often experience polypharmacy (defined as taking five or more regular medicines). Therefore, we need to ensure that residents only take the medications that are appropriate or provide value (also known as medicines optimisation). To achieve this, deprescribing, or the reduction or stopping of prescription medicines that may no longer be providing benefit, can help manage polypharmacy and improve outcomes. Various tools, guides, and approaches have been developed to help support health professionals to deprescribe in regular practice. Little evaluation of these tools has been conducted and no work has been done in the care home setting. OBJECTIVE This qualitative study aimed to assess distinct types of deprescribing tools for acceptability, feasibility, and suitability for the care home setting. METHODS Cognitive (think-aloud) interviews with care home staff in England were conducted (from December 2021 to June 2022) to assess five different deprescribing tools. The tools included a general deprescribing guidance, a generic (non-drug specific) deprescribing framework, a drug-specific deprescribing guideline/guide, a tool for identifying potentially inappropriate medications, and an electronic clinical decision support tool. Participants were recruited via their participation in another deprescribing study. The Consolidated Framework for Implementation Research informed the data collection and analysis. RESULTS Eight care home staff from 7 different care homes were interviewed. The five deprescribing tools were reviewed and assessed as not acceptable, feasible, or suitable for the care home setting. All would require significant modifications for use in the care home setting (e.g., language, design, and its function or use with different stakeholders). CONCLUSIONS As none of the tools were deemed acceptable, feasible, and suitable, future work is warranted to develop and tailor deprescribing tools for the care home setting, considering its specific context and users. Deprescribing implemented safely and successfully in care homes can benefit residents and the wider health economy.
Collapse
Affiliation(s)
- Krystal Warmoth
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK; National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK.
| | - Jessica Rees
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK; National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK
| | - Jo Day
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Emma Cockcroft
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Alex Aylward
- Peninsula Public Involvement Group, National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Lucy Pollock
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | | | | | - Bridget Walton
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Ken Stein
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| |
Collapse
|
2
|
Inskip M, Almendrales Rangel C, Njoku CM, Barnett F, Shih I, O’Neill L, Fiatarone Singh MA, Valenzuela T. The Frailty Reduction via Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial: Study Protocol and Recruitment Results. Methods Protoc 2024; 7:26. [PMID: 38525784 PMCID: PMC10961770 DOI: 10.3390/mps7020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 03/26/2024] Open
Abstract
INTRODUCTION Virtually all adults in aged care facilities are frail, a condition which contributes to falls, cognitive decline, hospitalisation, and mortality. Polypharmacy, malnutrition, sedentariness, and sarcopenia are risk factors amenable to intervention. The Asia-Pacific Frailty Management Guidelines recommend anabolic exercise and the optimisation of medications and nutrition. However, no study has evaluated this best practice intervention triad in aged care. METHODS The Frailty Reduction via the Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial (ANZCTR No.ACTRN12622000926730p) is a staged 6-month translational trial evaluating resident outcomes, staff/caregiver knowledge, and institutional implementation in a Townsville aged care facility. Residents received high-intensity resistance exercise and balance training and medication and nutrition optimisation co-implemented by investigators (exercise physiologist, geriatrician, pharmacist, and nutritionist) and facility staff. Staff and caregivers completed comprehensive education modules and training. We report the trial protocol and recruitment results. RESULTS 29 residents (21 female, age: 88.6 ± 6.3 years) were recruited. At baseline, the residents were frail (frailty scale nursing home (FRAIL-NH); 6.3 ± 2.4/14), cognitively impaired (Montreal Cognitive Assessment; 13.8 ± 6.8/30), functionally impaired (Short Physical Performance Battery; 4.9 ± 3.1/12, 6 min walk distance; 222.2 ± 104.4 m), and were prescribed numerous medications (15.5 ± 5.9). Two residents died and one withdrew before the intervention's commencement. Thirty family members and 19 staff (carers, allied health assistants, nurse managers, registered nurses, lifestyle-leisure officers, kitchen/hospitality staff, and senior leadership) were recruited to receive frailty education modules. CONCLUSIONS The FRIEND trial is currently being implemented with results expected in mid-2024. This is the first trial to evaluate the implementation of the best practice frailty guidelines including anabolic exercise and medication/nutritional optimisation in residential aged care.
Collapse
Affiliation(s)
- Michael Inskip
- College of Healthcare Sciences, James Cook University, Townsville, QLD 4814, Australia
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | - Carolina Almendrales Rangel
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | | | - Fiona Barnett
- College of Healthcare Sciences, James Cook University, Townsville, QLD 4814, Australia
| | - Isabel Shih
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | | | - Maria A. Fiatarone Singh
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- The Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA 02131, USA
| | - Trinidad Valenzuela
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago 7550196, Chile
| |
Collapse
|
3
|
Silva Almodóvar A, Keller MS, Lee J, Mehta HB, Manja V, Nguyen TPP, Pavon JM, Terman SW, Hoyle D, Mixon AS, Linsky AM. Deprescribing medications among patients with multiple prescribers: A socioecological model. J Am Geriatr Soc 2024; 72:660-669. [PMID: 37943070 PMCID: PMC10947820 DOI: 10.1111/jgs.18667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023]
Abstract
Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.
Collapse
Affiliation(s)
- Armando Silva Almodóvar
- Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jiha Lee
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Veena Manja
- Veterans Affairs Northern California Healthcare System, Mather, California, USA
- University of California Davis, Sacramento, California, USA
| | - Thanh Phuong Pham Nguyen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Samuel W Terman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Hoyle
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy M Linsky
- General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Cheng CHJ, Langford AV, Gnjidic D, Farrell BJ, Schneider CR. Survey content validation evaluating the dissemination and implementation of deprescribing guidelines. Basic Clin Pharmacol Toxicol 2024; 134:63-71. [PMID: 37357339 DOI: 10.1111/bcpt.13922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/24/2023] [Accepted: 06/22/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Policies, protocols and processes within organisations can facilitate or hinder guideline adoption. There is limited knowledge on the strategies used by organisations to disseminate and implement evidence-based deprescribing guidelines or their impact. METHODS We aimed to develop an online survey targeting key organisations involved in deprescribing guideline endorsement, dissemination, modification or translation internationally. Survey questions were drafted, mirroring the six components of the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Content validation was undertaken and established by a panel of clinicians, researchers and implementation experts. RESULTS A 52-item survey underwent two rounds of content validation. The minimum threshold (I-CVI > 0.78) for relevance and importance was met for 39 items (75%) in the first round and 44 of 48 items (92%) in the second round. The expert panel concluded that the adoption, implementation and effectiveness survey sections were largely relevant and important to this topic, whereas the reach and maintenance sections were harder to understand and may be less pertinent to the research question. CONCLUSIONS A 44-item survey investigating dissemination and implementation strategies for deprescribing guidelines has been developed and its content validated. Widespread survey distribution may identify effective strategies and inform dissemination and implementation planning for newly developed guidelines.
Collapse
Affiliation(s)
- Chun Hei Justin Cheng
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Aili V Langford
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre of Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Barbara J Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Canada
| | - Carl R Schneider
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Villavaso CD, Williams S, Parker TM. Polypharmacy in the Cardiovascular Geriatric Critical Care Population: Improving Outcomes. Crit Care Nurs Clin North Am 2023; 35:505-512. [PMID: 37838422 DOI: 10.1016/j.cnc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
The cardiovascular geriatric population requiring intensive or critical care is a group vulnerable to adverse outcomes because of age, the critical care environment, geriatric syndromes, and multiple chronic conditions. Polypharmacy increases the risk of adverse events in this group. Several tools and aids are available to guide the clinical practice of appropriate prescribing and deprescribing. To optimize the care of the cardiovascular geriatric population, evidence-based prescribing, and deprescribing tools can be implemented by the interprofessional team consisting of the patient, their support system, critical care nurses, advanced practice clinicians, physicians, and allied health professionals.
Collapse
Affiliation(s)
- Chloé Davidson Villavaso
- Clinical Faculty, Tulane University School of Medicine, Heart and Vascular Institute, 1430 Tulane Avenue #8548, New Orleans, LA 70112, USA.
| | | | - Tracy M Parker
- Touro Heart and Vascular Care, LCMC Health, 3715 Prytania Street, Suite 400, New Orleans, LA 70115, USA
| |
Collapse
|
6
|
Warmoth K, Rees J, Day J, Cockcroft E, Aylward A, Pollock L, Coxon G, Craig T, Walton B, Stein K. Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study. BMJ Open 2023; 13:e081305. [PMID: 37996237 PMCID: PMC10668129 DOI: 10.1136/bmjopen-2023-081305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES To explore the factors that may help or hinder deprescribing practice for older people within care homes. DESIGN Qualitative semistructured interviews using framework analysis informed by the Consolidated Framework for Implementation Research (CFIR). SETTING Participants were recruited from two care home provider organisations (a smaller independently owned organisation and a large organisation) in England. PARTICIPANTS A sample of 23 care home staff, 8 residents, 4 family members and 1 general practitioner were associated with 15 care homes. RESULTS Participants discussed their experiences and perceptions of implementing deprescribing within care homes. Major themes of (1) deprescribing as a complex process and (2) internal and external contextual factors influencing deprescribing practice (such as beliefs, abilities and relationships) were interrelated and spanned several CFIR constructs and domains. The quality of local relationships with and support from healthcare professionals were considered more crucial factors than the type of care home management structure. CONCLUSIONS Several influencing social and contextual factors need to be considered for implementing deprescribing for older adults in care homes. Additional training, tools, support and opportunities need to be made available to care home staff, so they can feel confident and able to question or raise concerns about medicines with prescribers. Further work is warranted to design and adopt a deprescribing approach which addresses these determinants to ensure successful implementation.
Collapse
Affiliation(s)
- Krystal Warmoth
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
- National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK
| | - Jessica Rees
- Department of Global Health & Social Medicine, King's College London, London, UK
| | - Jo Day
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Emma Cockcroft
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Alex Aylward
- Patient and Public Involvement Group, National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | | | | | | | - Bridget Walton
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Ken Stein
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| |
Collapse
|
7
|
Moreira PM, Aguiar EC, Castro PR, Almeida KC, Dourado JA, Paula SM, Melo MF, Santos PM, Oliveira MG. Optimizing Hypertension Treatment in Older Patients Through Home Blood Pressure Monitoring by Pharmacists in Primary Care: The MINOR Clinical Trial. Clin Ther 2023; 45:941-946. [PMID: 37365046 DOI: 10.1016/j.clinthera.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/29/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Incorporating technology such as home blood pressure monitoring (HBPM) into the clinical routine generates opportunities to improve BP monitoring and control in primary health care. It is also important to prevent overtreatment. However, the combination of HBPM with collaborative drug therapy management (CDTM) has not yet been studied. This study aimed to assess the efficacy of combining HBPM with CDTM to optimize hypertension treatment for older patients. METHODS This open-label, parallel-group, randomized clinical trial was conducted between June 2021 and August 2022 in a Brazilian community pharmacy and included older patients (aged ≥60 years) with hypertension. Those who were classified as poorly adherent or nonadherent to the prescribed drug treatment or who were unable to perform HBPM were excluded. In the control group, participants received a BP monitor and instructions on how to perform HBPM. A general practitioner, who was provided a report with the obtained BP values, determined any changes to the treatment protocol. In the intervention group, a pharmacist enrolled participants in a drug therapy management protocol and provided the general practitioner with suggestions to optimize the antihypertensive drug therapy, in addition to the report with the BP values. The following outcomes were considered: the proportion of participants receiving deprescriptions of antihypertensive drugs, other treatment adjustments, and the difference in mean BP between the groups 45 days after performing HBPM. The study used a t test combined with Levene's test to calculate mean intergroup differences in BP, the paired t test to calculate mean intragroup differences in BP, and Pearson's χ2 test to determine intergroup differences in changes in drug therapy. FINDINGS In each group, 161 participants completed the trial. Antihypertensive agents were deprescribed for 31 (19.3%) participants in the intervention group versus 11 (6.8%) in the control group (P = 0.01). In addition, 14 (8.7%) participants were prescribed antihypertensive drugs in the intervention group versus 11 (6.8%) in the control group (P = 0.52). The mean office systolic BP and HBPM values were lower in the intervention group (P = 0.22 and P = 0.29, respectively). IMPLICATIONS Combining HBPM with a CDTM protocol effectively optimized antihypertensive treatment for older patients in a primary health care setting. CLINICALTRIALS gov identifier: NCT04861727.
Collapse
Affiliation(s)
- Pablo Maciel Moreira
- Programa de Pós-Graduação em Saúde Coletiva, Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil
| | - Erlan Canguçu Aguiar
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil; Programa de Pós-Graduação em Assistência Farmacêutica em Rede e Associação de Instituições de Ensino Superior, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - Priscila Ribeiro Castro
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil
| | - Kleiton Coelho Almeida
- Programa de Pós-Graduação em Assistência Farmacêutica em Rede e Associação de Instituições de Ensino Superior, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - July Anne Dourado
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil
| | - Sabrina Miranda Paula
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil
| | - Milena Flores Melo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil
| | - Pablo Moura Santos
- Programa de Pós-Graduação em Assistência Farmacêutica em Rede e Associação de Instituições de Ensino Superior, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil
| | - Marcio Galvão Oliveira
- Programa de Pós-Graduação em Saúde Coletiva, Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Candeias, Vitória da Conquista, Brazil; Programa de Pós-Graduação em Assistência Farmacêutica em Rede e Associação de Instituições de Ensino Superior, Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Brazil.
| |
Collapse
|
8
|
Mangin D, Lamarche L, Templeton JA, Salerno J, Siu H, Trimble J, Ali A, Varughese J, Page A, Etherton-Beer C. Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER). Drugs Aging 2023; 40:857-868. [PMID: 37603255 PMCID: PMC10450010 DOI: 10.1007/s40266-023-01055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Polypharmacy, particularly among older adults, is gaining recognition as an important risk to health. The harmful effects on health arise from disease-drug and drug-drug interactions, the cumulative burden of side effects from multiple medications and the burden to the patient. Single-disease clinical guidelines fail to consider the complex reality of optimising treatments for patients with multiple morbidities and medications. Efforts have been made to develop and implement interventions to reduce the risk of harmful effects, with some promising results. However, the theoretical basis (or pre-clinical work) that informed the development of these efforts, although likely undertaken, is unclear, difficult to find or inadequately described in publications. It is critical in interpreting effects and achieving effectiveness to understand the theoretical basis for such interventions. OBJECTIVE Our objective is to outline the theoretical underpinnings of the development of a new polypharmacy intervention: the Team Approach to Polypharmacy Evaluation and Reduction (TAPER). METHODS We examined deprescribing barriers at patient, provider, and system levels and mapped them to the chronic care model to understand the behavioural change requirements for a model to address polypharmacy. RESULTS Using the chronic care model framework for understanding the barriers, we developed a model for addressing polypharmacy. CONCLUSIONS We discuss how TAPER maps to address the specific patient-level, provider-level, and system-level barriers to deprescribing and aligns with three commonly used models and frameworks in medicine (the chronic care model, minimally disruptive medicine, the cumulative complexity model). We also describe how TAPER maps onto primary care principles, ultimately providing a description of the development of TAPER and a conceptualisation of the potential mechanisms by which TAPER reduces polypharmacy and its associated harms.
Collapse
Affiliation(s)
- Dee Mangin
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada.
- Department of General Practice, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand.
| | - Larkin Lamarche
- School of Kinesiology and Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Jeffrey A Templeton
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Jennifer Salerno
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Henry Siu
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Johanna Trimble
- Patient Voices Network of BC, 201-750 Pender Street West, Vancouver, BC, V6C 2T8, Canada
| | - Abbas Ali
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Jobin Varughese
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Amy Page
- School of Allied Health, University of Western Australia, 35 Stirling Highway, Perth, WA, 6009, Australia
| | - Christopher Etherton-Beer
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, 35 Stirling Highway, Perth, WA, 6009, Australia
| |
Collapse
|
9
|
Mejías-Trueba M, Rodríguez-Pérez A, García-Cabrera E, Jiménez-Juan C, Sánchez-Fidalgo S. The Barriers to Deprescription in Older Patients: A Survey of Spanish Clinicians. Healthcare (Basel) 2023; 11:1879. [PMID: 37444713 DOI: 10.3390/healthcare11131879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/15/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVE There are barriers to deprescription that hinder its implementation in clinical practice. The objective of this study was to analyse the main barriers and limitations of the deprescription process perceived by physicians who care for multipathological patients. MATERIALS AND METHODS The "deprescription questionnaire of elderly patients" was adapted to an online format and sent to physicians in geriatrics. Question 1 is a reference to establish agreement or disagreement with this practice. The influence of different aspects of deprescription was analysed via the demographic characteristics of the clinicians and perceptions of the various barriers (questions 2-9) by means of bivariate analysis. Based on the latter, a multivariate model was carried out to demonstrate the relationship between barriers and the degree of deprescription agreement among respondents. RESULTS Of the 72 respondents, 72.2% were in favour of deprescribing. Regarding the analyses, the demographic characteristics did not influence rankings. The deprescription of preventive drugs and consensus with patients were associated with a positive attitude towards deprescribing, while withdrawing drugs prescribed by other professionals, time constraints and patient reluctance emerged as possible barriers. The only factor independently associated with deprescribing was lack of time. CONCLUSIONS Time was found to be the main barrier to deprescription. Training, the creation of multidisciplinary teams and integrated health systems are key facilitators.
Collapse
Affiliation(s)
- Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
- Departamento de Enfermedades Infecciosas, Microbiología y Parasitología, Grupo de Investigación en Enfermedades Infecciosas, Instituto de Biomedicina de Sevilla, Universidad de Sevilla/Consejo Superior de Investigaciones Científicas/Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, 28029 Madrid, Spain
| | - Aitana Rodríguez-Pérez
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
| | - Emilio García-Cabrera
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, 41009 Sevilla, Spain
| | - Carlos Jiménez-Juan
- Unidad de Gestión Clínica Medicina Interna, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain
| | - Susana Sánchez-Fidalgo
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Sevilla, 41009 Sevilla, Spain
| |
Collapse
|
10
|
Heinrich CH, McHugh S, McCarthy S, Donovan MD. Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland. PLoS One 2022; 17:e0274552. [PMID: 36520798 PMCID: PMC9754218 DOI: 10.1371/journal.pone.0274552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/31/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective. METHODS A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework. RESULTS Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process. CONCLUSION Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.
Collapse
Affiliation(s)
- Clara H. Heinrich
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
- * E-mail:
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork City, Co. Cork, Ireland
| | - Suzanne McCarthy
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
| | - Maria D. Donovan
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
| |
Collapse
|
11
|
Conklin J, Farrell B, Dilliott D, Richardson L, McCarthy L, Raman-Wilms L. Community engagement in a disengaged world: Developing and implementing educational workshops on deprescribing amid the COVID-19 pandemic. Can Pharm J (Ott) 2022; 156:8-13. [PMID: 36660418 PMCID: PMC9742724 DOI: 10.1177/17151635221139830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022]
Affiliation(s)
| | - Barbara Farrell
- Bruyère Research Institute, Ottawa,
Ontario,Department of Family Medicine,
University of Ottawa
| | | | | | - Lisa McCarthy
- Bruyère Research Institute, Ottawa,
Ontario,Institute for Better Health, Trillium
Health Partners, Mississauga,Leslie Dan Faculty of Pharmacy and
Department of Family and Community Medicine, University of
Toronto, Toronto, Ontario
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of
Health Sciences, University of Manitoba, Winnipeg,
Manitoba
| |
Collapse
|
12
|
Seppala LJ, Kamkar N, van Poelgeest EP, Thomsen K, Daams JG, Ryg J, Masud T, Montero-Odasso M, Hartikainen S, Petrovic M, van der Velde N. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age Ageing 2022; 51:afac191. [PMID: 36153749 PMCID: PMC9509688 DOI: 10.1093/ageing/afac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. METHODS DESIGN systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. ELIGIBILITY CRITERIA randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. STUDY RECORDS title/abstract and full-text screening by two reviewers. RISK OF BIAS Cochrane Collaboration revised tool. DATA SYNTHESIS results reported separately for different settings and sufficiently comparable studies meta-analysed. RESULTS forty-nine heterogeneous studies were included. COMMUNITY meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85-1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70-1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69-1.14, I2 = 0%, 2 s) for injurious falls. HOSPITAL meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74-1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07-3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. LONG-TERM CARE meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72-1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64-1.35, I2 = 92%, 7 s) for number of falls. CONCLUSIONS the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls.PROSPERO registration number: CRD42020218231.
Collapse
Affiliation(s)
- Lotta J Seppala
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Nellie Kamkar
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Katja Thomsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Joost G Daams
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- ODIN (Odense Deprescribing INitiative), Denmark
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manuel Montero-Odasso
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Schulich School of Medicine and Dentistry, London Ontario, Canada
- Departments of Medicine (Geriatrics) and of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | | | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Development and Validation of Comprehensive Healthcare Providers' Opinions, Preferences, and Attitudes towards Deprescribing (CHOPPED Questionnaire). PHARMACY 2022; 10:pharmacy10040076. [PMID: 35893715 PMCID: PMC9326567 DOI: 10.3390/pharmacy10040076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
Successful implementation of deprescribing requires exploring healthcare professionals’ opinions, preferences, and attitudes towards deprescribing. The aim of this study was to develop and validate the questionnaire exploring healthcare providers’ opinions preferences and attitudes towards deprescribing (CHOPPED questionnaire). This was a cross-sectional on-line survey. A comprehensive 58-item questionnaire, in two versions (for pharmacists and physicians), was developed through an extensive literature review and interviews with experts. The questionnaire was validated, and its reliability was assessed through data collected from 356 pharmacists and 109 physicians. Exploratory factor analysis was performed, and 37- and 35-item questionnaires were developed. Ten factors were identified: knowledge, awareness, patient barriers and facilitators, competencies barriers and facilitators, collaboration barriers and facilitators, and healthcare system barriers and facilitators. The CHOPPED tool has satisfactory face, content (CVR > 0.62) (content validity ratio), construct, and criterion validity. The reliability statistics of all factors in both versions was acceptable with Cronbach’s alpha > 0.6. Test−retest reliability analysis showed that gamma rank correlations of total factor scores were strong and very strong (between 0.519 and 0.938). The CHOPPED tool can be used as a valid and reliable tool to explore healthcare providers’ opinions and attitudes toward discontinuing medications in the primary care setting in Croatia.
Collapse
|
14
|
McCarthy M, Mak S, Kaufmann CN, Lum HD, Fung CH. Care coordination needs for deprescribing benzodiazepines and benzodiazepine receptor agonists. Res Social Adm Pharm 2022; 18:2691-2694. [PMID: 34229951 PMCID: PMC8720104 DOI: 10.1016/j.sapharm.2021.06.025] [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: 04/27/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
Deprescribing of medications such as benzodiazepines and benzodiazepine receptor agonists (z-drugs) can be a complex process that varies across practices, specialties, and health care systems. Care coordination among healthcare providers, patients, families, and other healthcare system components is critical to achieving high levels of deprescribing and person-centered care. We present a framework for promoting care coordination in the context of benzodiazepine/z-drug deprescribing. Future efforts are needed to study the impact of better care coordination on benzodiazepines/z-drug discontinuation and other outcomes that are important to stakeholders.
Collapse
Affiliation(s)
- Michaela McCarthy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, Denver, CO,College of Nursing, University of Colorado, Aurora, CO
| | - Selene Mak
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Christopher N. Kaufmann
- Division of Epidemiology and Data Science in Gerontology, Department of Aging and Geriatric Research, University of Florida, Gainesville, FL
| | - Hillary D. Lum
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Health Care System, Aurora, CO,Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Constance H. Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
15
|
Deprescribing: What is the gold standard? Themes that characterized the discussions at the first Danish symposium on evidence-based deprescribing. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 5:100102. [PMID: 35478500 PMCID: PMC9030658 DOI: 10.1016/j.rcsop.2022.100102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 11/12/2021] [Accepted: 01/04/2022] [Indexed: 11/23/2022] Open
Abstract
The first Danish symposium on evidence-based deprescribing was held in September 2019. The symposium aimed to increase the awareness of deprescribing in general, to discuss the importance of deprescribing, and, thus, a potential consensus on key issues on a national deprescribing agenda. The invited keynote speaker, Barbara Farrell, from the Bruyére Research Institute, Ottawa, Canada, presented their thorough work on deprescribing guideline development and application. The symposium consisted of two parts: Part 1 concentrated on establishing the need for deprescribing in our society. Part 2 consisted of a panel debate that put the practical application and implementation of deprescribing in perspective to the input from the audience and the structure of the Danish healthcare system. The panelists represented key stakeholders, e.g., clinical pharmacists, general practitioners, hospital doctors, Danish Health Authority representatives, health politicians concerning deprescribing in Denmark. The event allowed 145 participants to discuss the importance of implementing deprescribing in a Danish setting. This commentary highlights and discusses the major themes that characterized the symposium: “why deprescribe?”, “deprescribing research” and a theme dedicated to “problems of concern.” The emergence of these themes formed the basis for the discussion of new strategies and a proposal for a future gold standard to succeed in deprescribing.
Collapse
|
16
|
Farrell B, Dilliott D, Richardson L, Conklin J, McCarthy LM, Raman-Wilms L. “Talking About Your Medications”: A workshop series aimed at helping older adults participate in conversations about their medications. Can Pharm J (Ott) 2022; 155:86-92. [PMID: 35300023 PMCID: PMC8922225 DOI: 10.1177/17151635221076075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, Ottawa, Ontario
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario
| | | | | | - James Conklin
- Bruyère Research Institute, Ottawa, Ontario
- Concordia University, Montreal, Quebec
| | - Lisa M. McCarthy
- Bruyère Research Institute, Ottawa, Ontario
- Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine
| | - Lalitha Raman-Wilms
- University of Toronto, Toronto, Ontario; and the College of Pharmacy
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| |
Collapse
|
17
|
Heinrich CH, Hurley E, McCarthy S, McHugh S, Donovan MD. Barriers and enablers to deprescribing in long-term care facilities: a 'best-fit' framework synthesis of the qualitative evidence. Age Ageing 2022; 51:6514232. [PMID: 35077555 DOI: 10.1093/ageing/afab250] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers' (HCWs) engagement with deprescribing in LTCFs. METHODS the 'best-fit' framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers. RESULTS of 655 records identified, 14 met the inclusion criteria. The 'best-fit' framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an 'established hierarchy' within LTCFs, negatively affecting communication and insufficient resources which limited HCWs' engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients' condition to influence decisions. DISCUSSION this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.
Collapse
|
18
|
Davila H, Rosen AK, Stolzmann K, Zhang L, Linsky AM. Factors influencing providers' willingness to deprescribe medications. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Heather Davila
- 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
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Department of Surgery Boston University School of Medicine Boston Massachusetts USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Libin Zhang
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Amy M. Linsky
- 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
- General Internal Medicine VA Boston Healthcare System Boston Massachusetts USA
| |
Collapse
|
19
|
Santamaría González M, Ruiz Mínguez MÁ, Arrebola Ramírez MM, Filella Pla X, Torrejón Martínez MJ, Morell García D, Castaño López MÁ, Allué Palacín JA, Albaladejo Otón MD, Giménez Gómez N. An opportunity to emphasize the relevance of laboratory medicine. ADVANCES IN LABORATORY MEDICINE 2021; 2:432-450. [PMID: 37362412 PMCID: PMC10197410 DOI: 10.1515/almed-2021-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/11/2021] [Indexed: 06/28/2023]
Abstract
Objectives Clinical practice guidelines (CPGs) are recommendations based on a systematic review of scientific evidence that are intended to help healthcare professionals and patients make the best clinical decisions. CPGs must be evidence-based and are designed by multidisciplinary teams. The purpose of this study is to assess the topics related to the clinical laboratory addressed in CPGs and evaluate the involvement of laboratory professionals in the CPG development process. Methods A total of 16 CPGs recommended by the Spanish Society of Laboratory Medicine and/or retrieved from PubMed-Medline were included. A review of the information provided in CPGs about 80 topics related to the clinical laboratory was performed. The authorship of laboratory professionals was assessed. Results On average, the 16 CPGs addressed 49% (standard deviation [SD]: 11%) of the topics evaluated in relation to the clinical laboratory. By order of frequency, CPGs contained information about 69% of postanalytical variables (SD: 20%); 52% of preanalytical variables (SD: 11%); and 43% of the analytical variables studied (SD: 18%). Finally, half the CPGs included a laboratory professional among its authors. Conclusions CPGs frequently failed to provide relevant laboratory-related information. Laboratory professionals were co-authors in only half the CPGs. There is scope for improvement, and laboratory professionals should be included in multidisciplinary teams involved in the development of CPGs.
Collapse
Affiliation(s)
- María Santamaría González
- Service of Clinical Biochemistry, Miguel Servet University Hospital, Zaragoza, Spain
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
| | - María Ángels Ruiz Mínguez
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Service of Laboratory Medicine, Fundació Hospital de l’Esperit Sant, Santa Coloma de Gramenet, Barcelona, Spain
| | - María Monsalud Arrebola Ramírez
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Laboratory Clinical Management Unit, Hospital de la Axarquía (AGSEMA), Málaga, Spain
| | - Xavier Filella Pla
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Service of Biochemistry and Molecular Genetics (CDB), Hospital Clinic, IDIBAPS, Barcelona, Spain
- Commission of Evidence-Based Laboratory Medicine, International Federation of Clinical Chemistry (IFCC), Milan, Italy
| | - María José Torrejón Martínez
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Clinical Biochemistry Management Unit (UGC), Hospital Clínico San Carlos, Madrid, Spain
| | - Daniel Morell García
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Service of Laboratory Medicine, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Miguel Ángel Castaño López
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Service of Clinical Biochemistry, Hospital Clínico Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Juan Antonio Allué Palacín
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Synlab Diagnosticos Globales, Sevilla, Spain
| | - María Dolores Albaladejo Otón
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Service of Laboratory Testing and Clinical Biochemistry, Santa Lucía University Hospital, Cartagena, Spain
| | - Nuria Giménez Gómez
- Commission of Evidence-Based Laboratory Medicine, Spanish Society of Laboratory Medicine (SEQC), Barcelona, Spain
- Research Unit, Research Foundation, Mutua de Terrassa, University of Barcelona, Barcelona, Spain
- Laboratory of Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Commission of Evidence-Based Laboratory Medicine, International Federation of Clinical Chemistry (IFCC), Milan, Italy
| |
Collapse
|
20
|
Pruskowski JA, Kane-Gill SL, Kavalieratos D, Wilson BK, Arnold RM, Handler SM. Feasibility of an Academic Detailing Intervention to Support Deprescribing in the Nursing Home. J Am Med Dir Assoc 2021; 22:2398-2400.e4. [PMID: 34324872 DOI: 10.1016/j.jamda.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jennifer A Pruskowski
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | | | | | | | - Robert M Arnold
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven M Handler
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| |
Collapse
|
21
|
Coskun Benlidayi I, Gokce Kutsal Y. Antirheumatic drugs in older adults and polypharmacy issues. Z Gerontol Geriatr 2021; 55:507-512. [PMID: 34114088 DOI: 10.1007/s00391-021-01907-6] [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: 03/18/2021] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Older individuals experience various noninflammatory and autoimmune inflammatory rheumatic diseases. Given the increased incidence of rheumatic conditions in older adults, it is of great importance for healthcare providers to be aware of the potential benefits and risks of antirheumatic drugs. The present article aims to provide a comprehensive review regarding antirheumatic drug use in older patients, particularly by focusing on safety issues and polypharmacy. Antirheumatic medications include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and disease-modifying antirheumatic drugs (DMARDs), which comprise conventional synthetic DMARDs, targeted synthetic DMARDs and biological DMARDs. Due to the alteration in drug pharmacokinetics and pharmacodynamics in old people, antirheumatic drug efficiency and safety may be different than in the younger population. Polypharmacy and multimorbidity are other potential challenges to be faced during the treatment of older patients with rheumatic diseases. The current review also discusses the strategies to minimize adverse reactions due to antirheumatic drugs.
Collapse
Affiliation(s)
- Ilke Coskun Benlidayi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana, Turkey.
| | - Yesim Gokce Kutsal
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
22
|
Abebe E, Campbell NL, Clark DO, Tu W, Hill JR, Harrington AB, O'Neal G, Trowbridge KS, Vallejo C, Yang Z, Bo N, Knight A, Alamer KA, Carter A, Valenzuela R, Adeoye P, Boustani MA, Holden RJ. Reducing anticholinergic medication exposure among older adults using consumer technology: Protocol for a randomized clinical trial. Res Social Adm Pharm 2021; 17:986-992. [PMID: 33773639 PMCID: PMC8007932 DOI: 10.1016/j.sapharm.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION A growing body of scientific evidence points to the potentially harmful cognitive effects of anticholinergic medications among older adults. Most interventions designed to promote deprescribing of anticholinergics have directly targeted healthcare professionals and have had mixed results. Consumer-facing technologies may provide a unique benefit by empowering patients and can complement existing healthcare professional-centric efforts. METHODS We initiated a randomized clinical trial to evaluate the effectiveness of a patient-facing mobile application (Brain Safe app) compared to an attention control medication list app in reducing anticholinergic exposure among community-dwelling older adults. Study participants are adults aged 60 years and above, currently using at least one prescribed strong anticholinergic, and receiving primary care. The trial plans to enroll a total of 700 participants, randomly allocated in 1:1 proportion to the two study arms. Participants will have the Brain Safe app (intervention arm) or attention control medication list app (control arm) loaded onto a smartphone (study provided or personal device). All participants will be followed for 12 months and will have data collected at baseline, at 6 months, and 12 months by blinded outcome assessors. The primary outcome of the study is anticholinergic exposure measured as total standard daily dose (TSDD) computed from medication prescription electronic records. Secondary outcomes of the study are cognitive function and health-related quality of life. DISCUSSION A consumer-facing intervention to promote deprescribing of potentially high-risk medications can be part of a multi-pronged approach to reduce inappropriate medication use among older adult patients. Delivering a deprescribing intervention via a mobile app is a novel approach and may hold great promise to accelerate deployment of medication safety initiatives across diverse patient populations. CLINICAL TRIAL REGISTRATION Registered at ClinicalTrials.gov on October 10, 2019. Identifier number: NCT04121858.
Collapse
Affiliation(s)
- Ephrem Abebe
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, IN, USA; Eskenazi Health, Indianapolis, IN, USA
| | - Daniel O Clark
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jordan R Hill
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Addison B Harrington
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Gracen O'Neal
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Kimberly S Trowbridge
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Christian Vallejo
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Ziyi Yang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Na Bo
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexxus Knight
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Khalid A Alamer
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - Allie Carter
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robin Valenzuela
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Philip Adeoye
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Malaz A Boustani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN, USA; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, USA
| | - Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
23
|
Soong C, Burry L, Greco M, Tannenbaum C. Advise non-pharmacological therapy as first line treatment for chronic insomnia. BMJ 2021; 372:n680. [PMID: 33757960 DOI: 10.1136/bmj.n680] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Christine Soong
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health, Toronto, ON M5G 1X5, Canada
- Centre for Quality and Patient Safety, University of Toronto, ON, Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | | | - Cara Tannenbaum
- Faculté de Médicine, Institut Universitaire de Gériatrie de Montreal, Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
24
|
Nightingale G, Mohamed MR, Holmes HM, Sharma M, Ramsdale E, Lu-Yao G, Chapman A. Research priorities to address polypharmacy in older adults with cancer. J Geriatr Oncol 2021; 12:964-970. [PMID: 33589379 DOI: 10.1016/j.jgo.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/31/2021] [Accepted: 01/31/2021] [Indexed: 11/25/2022]
Abstract
Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities-Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions-highlight critical areas for future research to improve outcomes for older adults with cancer.
Collapse
Affiliation(s)
- Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Mostafa R Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Holly M Holmes
- McGovern Medical School, University of Texas Health Science Center of Houston, Houston, TX, USA
| | - Manvi Sharma
- Pharmacy Administration, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Grace Lu-Yao
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA; Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA; Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Andrew Chapman
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA; Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| |
Collapse
|
25
|
Dirks RC, Walsh D, Haggerty S, Kohn GP, Pryor A, Stefanidis D. SAGES guidelines: an appraisal of their quality and value by SAGES members. Surg Endosc 2021; 35:1493-1499. [PMID: 33528662 DOI: 10.1007/s00464-021-08323-2] [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] [Received: 10/27/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee develops evidence-based guidelines for practicing surgeons using standard methodology. Our objective was to survey the SAGES membership regarding guidelines' quality, use, and value and identify topics of interest for new guideline development. METHODS An anonymous online survey was emailed in October 2019 to SAGES members. Respondents were asked 18 questions on their use and evaluation of SAGES guidelines and SAGES reviews and to provide suggestions for new guideline topics and areas of improvement. The survey was open for 6 weeks with a 3-week reminder. RESULTS Of 548 responders, most were minimally invasive (41%) or general surgeons (33%). There was an even distribution between academic (46%) and non-academic practice (24% private practice, 23% hospital employed). Most used SAGES guidelines frequently (22%) or occasionally (68%) and found them to be of value (83%), above average quality (86%), and easy to use (74%). While most stated it was important (35%) or very important (58%) that SAGES continues to follow "rigorous guidelines development processes," common suggestions were for more timely updates and improved web access. Of 442 overlapping topic suggestions, 60% fell into overarching categories of hernia, bariatric, robotic, HPB, and colorectal surgery. CONCLUSIONS The SAGES guidelines are used frequently and valued by its users for their quality and content. Topics proposed by SAGES members and valuable insight from this survey can guide creation of new guidelines and refinement of established guidelines and processes.
Collapse
Affiliation(s)
- Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Danielle Walsh
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Stephen Haggerty
- Division of Gastrointestinal and General Surgery, NorthShore University Healthsystem, Evanston, IL, USA
| | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Aurora Pryor
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. .,, 11725 North Illinois Street, Suite 350, Carmel, IN, 46032, USA.
| |
Collapse
|
26
|
Elbeddini A, Prabaharan T, Almasalkhi S, Tran C, Zhou Y. Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic. Res Social Adm Pharm 2021; 17:1942-1945. [PMID: 32499161 PMCID: PMC7256521 DOI: 10.1016/j.sapharm.2020.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 01/16/2023]
Abstract
Deprescribing aims to reduce polypharmacy, especially in the elderly population, in order to maintain or improve quality of life, reduce harm from medications, and limit healthcare expenditure. Coronavirus disease (COVID-19) is an infectious disease that has led to a pandemic and has changed the lives many throughout the world. The mode of transmission of this virus is from person to person through the transfer of respiratory droplets. Therefore, non-essential healthcare services involving direct patient interactions, including deprescribing, has been on hiatus to reduce spread. Barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. Some of these barriers can be mitigated by using the following interventions:patient education, prioritization of non-pharmacological therapy, incorporation of electronic health record (EHR), continuous prescriber education, and development of research studies on deprescribing. Currently, deprescribing cannot be delivered through in person interactions, so virtual care is a reasonable alternative format. The full incorporation of EHR throughout Canada can add to the success of this strategy. However, there are several challenges of conducting deprescribing virtually in the elderly population. These challenges include, but are not limited, to their inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. Virtual care is the future of healthcare and in order to retain the benefits of deprescribing, additional initiatives should be in place to address the challenges that elderly patients may experience in accessing deprescribing virtually. These initiatives should involve teaching elderly patients how to use technology to access health services and with technical support in place to address any concerns.
Collapse
Affiliation(s)
- Ali Elbeddini
- Winchester District Memorial Hospital, 566 Louise Street, Winchester, ON, KK0C2K0, Canada.
| | - Thulasika Prabaharan
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, M5S 3M2, Canada.
| | - Sarah Almasalkhi
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, M5S 3M2, Canada.
| | - Cindy Tran
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, M5S 3M2, Canada.
| | - Yueyang Zhou
- Faculty of Science, University of Ottawa, 75 Laurier Ave. East, Ottawa, ON, K1N 6N5, Canada.
| |
Collapse
|
27
|
Isenor JE, Bai I, Cormier R, Helwig M, Reeve E, Whelan AM, Burgess S, Martin-Misener R, Kennie-Kaulbach N. Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review. Res Social Adm Pharm 2020; 17:1229-1241. [PMID: 32978088 DOI: 10.1016/j.sapharm.2020.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 09/07/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review. OBJECTIVE This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW). METHODS A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT). RESULTS Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion. CONCLUSIONS Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.
Collapse
Affiliation(s)
- Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Isaac Bai
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Rachel Cormier
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
| | | |
Collapse
|
28
|
Cateau D, Ballabeni P, Mena S, Bugnon O, Niquille A. Deprescribing in nursing homes: Protocol for nested, randomised controlled hybrid trials of deprescribing interventions. Res Social Adm Pharm 2020; 17:786-794. [PMID: 32622774 DOI: 10.1016/j.sapharm.2020.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Polypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level. METHODS AND ANALYSIS The first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible. The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate. Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators. ETHICS, REGISTRATION AND FUNDING Both trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.
Collapse
Affiliation(s)
- Damien Cateau
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland.
| | - Pierluigi Ballabeni
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Stephanie Mena
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Olivier Bugnon
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Anne Niquille
- Community Pharmacy, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| |
Collapse
|
29
|
Room for improvement in reporting of trials discontinuing long-term medication: a systematic review. J Clin Epidemiol 2020; 119:65-74. [DOI: 10.1016/j.jclinepi.2019.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/20/2019] [Accepted: 11/19/2019] [Indexed: 12/23/2022]
|
30
|
Abstract
Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.
Collapse
|
31
|
Rivera J, Shcherbakova N, Vala C, Capoccia K. Community pharmacists' interventions and documentation during medication therapy management encounters delivered face-to-face versus via telephone: The devil is in the details. Res Social Adm Pharm 2020; 16:1447-1451. [PMID: 31889640 DOI: 10.1016/j.sapharm.2019.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/21/2019] [Accepted: 12/22/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND To date, no studies are available comparing in-person versus telephone-administered medication therapy management (MTM) encounters in a community pharmacy setting with respect to medication-related problems, interventions and documentation. OBJECTIVE The objective of this study was to evaluate types of medication-related problems, interventions, and documentation among patients receiving MTM face-to-face versus over the telephone. METHODS A retrospective analysis was performed on all completed comprehensive medication reviews (CMR) between 2011 and 2017 in 14 community pharmacies in Western Massachusetts, USA that belong to one district of a national chain. Medication-related problems were classified as: Beers criteria medications, untreated condition, dose too high or low, medication omission, duplicate therapy, drug-drug interaction, non-adherence, complicated dosing. Pharmacist's interventions were classified as education, medication reconciliation, and vaccination. Documentation of assessment, plan, discussion notes, and recommendations were evaluated as being present or absent. RESULTS In total, 297 encounters (56.5% were over the telephone) were included in the analysis. There was no significant differences between clinical and demographic characteristics and types of medication-related problems and pharmacist interventions among patients who received face-to-face versus telephone MTM service. Assessment was documented among 28% of face-to-face and 42% of telephone CMR encounters (p < 0.05). Plan was documented among 27% of face-to-face and 40% of telephone CMR encounters (p < 0.05). Discussion notes were documented among 97% of face-to-face and 98% of telephone CMR encounters (p > 0.05). Pharmacist recommendations were documented among 92% of face-to-face and 95% of telephone CMR encounters (p > 0.05). CONCLUSIONS Pharmacists identify medication-related problems and provide education and medication reconciliation interventions independent of the mode of delivery. The overall low frequency of assessment and plan documentation raises concerns. It is imperative for pharmacists to document both instances of provider outreach and follow-up to ascertain resolutions of patients' medication-related problems.
Collapse
Affiliation(s)
| | - Natalia Shcherbakova
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA.
| | | | - Kam Capoccia
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA
| |
Collapse
|
32
|
Zimmerman KM, Linsky AM, Donohoe KL, Hobgood SE, Sargent L, Salgado TM. An Interprofessional Workshop to Enhance De-prescribing Practices Among Health Care Providers. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2020; 40:49-57. [PMID: 32149948 DOI: 10.1097/ceh.0000000000000280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION De-prescribing is a complex behavior that benefits from a multifaceted approach to learning. We sought to create and deliver a 1-day interprofessional workshop to enhance de-prescribing knowledge and skills among health care professionals. METHODS Workshop development was based on the Adult Learning Theory and the Theoretical Domains Framework. The workshop addressed provider-related barriers, was created and delivered by an interprofessional team, and combined didactic and active learning techniques. Targeted participants included physicians, advanced practice providers (nurse practitioners and physician's assistants), pharmacists, and clinic staff. Interprofessional workgroups were created a priori. Participants were asked to complete a postprogram evaluation, including whether they would implement changes to practice, teaching, research, or administrative duties after participation. RESULTS We created an in-person, 5.5 credit hour, interprofessional de-prescribing workshop that comprised six sessions: (1) polypharmacy and de-prescribing overview; (2) identification of potentially inappropriate medications; (3) prioritization of medications for de-prescribing; (4) design and implementation of a de-prescribing plan; (5) principles for a patient-centered approach; and (6) suggestions for successful collaboration. Forty-one participants attended the workshop, and 38 (92.7%) completed the postprogram assessment. Participants felt they were likely to implement changes in practice, teaching, research, or administrative duties, rating themselves with a mean of 9.2 (SD = 1.06) on a 1 to 10 scale. Ultimately, 96.6% would recommend the workshop to others. DISCUSSION Based on participant feedback, the workshop catalyzed intention to change practice, teaching, research, or administrative duties. Other institutions seeking to change the complex behavior of de-prescribing may wish to model this development and delivery strategy.
Collapse
Affiliation(s)
- Kristin M Zimmerman
- Mrs. Zimmerman: Associate Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA. Dr. Linsky: Assistant Professor, VA Boston Healthcare System, Department of Medicine, Center for Healthcare Organization and Implementation Research, and Assistant Professor, Boston University School of Medicine, Boston, MA. Dr. Donohoe: Associate Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA. Dr. Hobgood: Associate Professor, Department of Internal Medicine, Division of Geriatric Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. Dr. Sargent: Assistant Professor, Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, VA. Dr. Salgado: Assistant Professor, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | | | | | | | | | | |
Collapse
|
33
|
Reducing Inappropriate Drug Use in Older Patients by Use of Clinical Decision Support in Community Pharmacy: A Mixed-Methods Evaluation. Drugs Aging 2019; 37:115-123. [DOI: 10.1007/s40266-019-00728-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
34
|
Abstract
There is increasing concern among patients and health care providers about the associations between PPI use and a multitude of potential adverse outcomes. Therefore, clinicians need to have a rational approach both to identifying PPI users who may not have an ongoing indication for their use and on how to encourage discontinuation of unnecessary PPI use. In this paper, we will provide a detailed review of the specific indications where the benefits of ongoing PPI use is of questionable value and will review the evidence on how to maximize the likelihood of being able to successfully discontinue PPI use while minimizing symptom recurrence.
Collapse
|
35
|
Rogan EL, Ranson CA, Valle-Oseguera CS, Lee C, Gumberg A, Nagin BN, Cao W, Wang E, Trinh C, Chan K, Samra NK, Hou EW, Patel RA. Factors associated with medication-related problems in an ambulatory medicare population and the case for medication therapy management. Res Social Adm Pharm 2019; 16:783-786. [PMID: 31447267 DOI: 10.1016/j.sapharm.2019.08.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Medication-related problems (MRPs) are a major healthcare burden. The rate of MRPs in those ≥65 years old is ∼50 events per 1000 person-years, and contributes to a four-fold higher hospitalization rate when compared to younger patients. Medication therapy management (MTM) can identify MRPs in high-risk patients. However, in 2015, only 12.9% of Medicare patients qualified for MTM services through their Part D plan. OBJECTIVE To examine the type and frequency of MRPs in community-dwelling Medicare beneficiaries and which patient factors are associated with having ≥1 MRP. METHODS Fourteen health clinics targeting Medicare beneficiaries were held in 10 Northern/Central California cities during Fall 2017. Trained student pharmacists, supervised by licensed pharmacists, conducted comprehensive medication reviews. Sociodemographic, chronic condition, medication, and MRP data were collected via standardized surveys. RESULTS MTM services were provided to 910 patients, of which 633 (69.6%) had at least 1 MRP. The most common MRPs were severe drug-drug interaction [n = 297(33.4%)] and untreated condition [n = 134 (14.7%). Individuals with MRPs took significantly more prescription and over-the-counter medications. Additionally, those with MRPs were more likely to be subsidy recipients and in a Medicare Advantage Prescription Drug Plan. A total of 120 (13%) individuals were found to have had an MRP severe enough to warrant prescriber follow-up. CONCLUSIONS Although only a fraction of Medicare beneficiaries qualify for MTM services through their Part D plan, many can benefit from such services. Understanding the type, frequency, and factors contributing to MRPs is imperative to identify and avoid negative sequelae. Reduction of MRPs can potentially improve patient clinical outcomes, increase quality-of-life, and decrease overall cost of care.
Collapse
Affiliation(s)
- Edward L Rogan
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Carly A Ranson
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Cynthia S Valle-Oseguera
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Cynthia Lee
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Anthony Gumberg
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Basirh N Nagin
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Wenwan Cao
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Eileen Wang
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Catherine Trinh
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Kevin Chan
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Navpreet Kaur Samra
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Emily Win Hou
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| | - Rajul A Patel
- University of the Pacific Thomas J. Long School of Pharmacy, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
| |
Collapse
|
36
|
Thakur T, Frey M, Chewning B. Pharmacist Services in the Opioid Crisis: Current Practices and Scope in the United States. PHARMACY 2019; 7:pharmacy7020060. [PMID: 31200469 PMCID: PMC6632048 DOI: 10.3390/pharmacy7020060] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/01/2019] [Accepted: 06/06/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction: Pharmacist roles promoting safe opioid use are recognized in literature and practice. Pharmacists can offer services such as counseling on opioid risks, naloxone dispensing, education on opioid storage and disposal, prescription drug monitoring program (PDMP) utilization, opioid deprescribing, and providing resources for addiction treatment to help mitigate the opioid crisis. Objective: This commentary seeks to describe current and potential roles for pharmacists to combat the United States opioid crisis and identify key factors affecting service provision. Methods: The paper summarizes evidence-based studies describing current pharmacist roles and services, factors affecting service implementation, and strategies to further improve pharmacist roles and services related to promoting safe opioid use for patients. Results: Pharmacists recognize their roles and responsibilities to counsel patients on opioid risks, dispense naloxone, educate on opioid storage and disposal, utilize prescription drug monitoring programs (PDMPs), offer opioid deprescribing, and provide resources for addiction treatment. However, pharmacists express low confidence, time, and training as barriers to service provision. This suggests a need for structured training, resources, and organizational support for pharmacists to improve confidence and participation in such services. Conclusions: Although pharmacists are aware of roles and responsibilities to help reduce the opioid crisis, more training, education, organizational support and resources are needed to increase their ability to embody these roles.
Collapse
Affiliation(s)
- Tanvee Thakur
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, USA.
| | - Meredith Frey
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, USA.
| | - Betty Chewning
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, USA.
| |
Collapse
|