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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.
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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
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [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: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Rea E, Portman D, Ioannou K, Lumley B. Pharmacist-driven deprescribing initiative in primary care. J Am Pharm Assoc (2003) 2024; 64:139-145. [PMID: 37722503 DOI: 10.1016/j.japh.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/29/2023] [Accepted: 09/12/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Polypharmacy, a broad term to describe the use of numerous and often unnecessary medications, has been connected to frailty, hospital admissions, falls, and even mortality. The Veterans Health Administration (VHA) developed the VIONE (vital, important, optional, not indicated, and every medication has an indication) dashboard to identify patients with polypharmacy and serve as a framework for deprescribing of medications across VHA facilities where it is used in a variety of practice settings by different disciplines. OBJECTIVE This study aimed to describe the implementation of a pharmacist-led, system-wide, deprescribing initiative in the primary care setting. PRACTICE DESCRIPTION Interdisciplinary education was provided through academic detailing. Subsequently, patients were identified for inclusion in the project using the VIONE dashboard focusing on those at highest risk of polypharmacy and moving down to the lowest risk. Interested patients underwent a medication reconciliation. A clinical pharmacist practitioner (CPP) then contacted the patient to discuss potential deprescribing options. Recommendations were relayed to the primary care provider (PCP) for final approval and communicated to the patient by the pharmacy team. PRACTICE INNOVATION Primary care CPPs (n = 3) integrated deprescribing into their standard workload. This service was implemented in the primary care setting across an entire health care system consisting of 16 different primary care teams. EVALUATION METHODS The initiative's impact was measured by the number of discontinued medications, the acceptance rate of recommendations by the PCP, the potential annualized cost avoidance, and the number of patients referred to CPP medication management clinics. RESULTS Among 63 patients, a total of 352 medications were deprescribed resulting in a potential annualized cost avoidance of $184,221. The acceptance rate of discontinuation recommendations was 96.7%. Subsequently, 25.4% of patients were referred to pharmacist-led clinics for disease state management. CONCLUSION Embedding deprescribing into standard CPP workflow within the primary care setting facilitated a way for polypharmacy reduction and allowed the expansion of pharmacy-led services at VA Butler Healthcare System.
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Hall RK, Rutledge J, Lucas A, Liu CK, Clair Russell JS, Peter WS, Fish LJ, Colón-Emeric C. Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis. Clin J Am Soc Nephrol 2023; 18:1310-1320. [PMID: 37499693 PMCID: PMC10578639 DOI: 10.2215/cjn.0000000000000229] [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: 02/14/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics. METHODS We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020. RESULTS We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits). CONCLUSIONS Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.
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Affiliation(s)
- Rasheeda K. Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jeanette Rutledge
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anika Lucas
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Christine K. Liu
- Section of Geriatric Medicine, Stanford University School of Medicine, Stanford, California
- Geriatric Research Education and Clinical Center, Palo Alto VA Health Care System, Palo Alto, California
| | - Jennifer St. Clair Russell
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Dimensions of Care, LLC, Rockville, Maryland
| | - Wendy St. Peter
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Laura J. Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
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Farrell B, Rousse-Grossman J, Santamaria C, McCarthy LM. Applying the Behaviour Change Wheel to support deprescribing in long-term care: Qualitative interviews with stakeholder participants. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100256. [PMID: 37091629 PMCID: PMC10113898 DOI: 10.1016/j.rcsop.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Background Implementation and behavioural science are increasingly being used to support development and translation of evidence-based interventions into practice. We used the Behaviour Change Wheel (BCW) approach in two stakeholder forums to identify target behaviours and supporting actions to inform the development of a framework to support deprescribing in long-term care homes. During our planning for these forums, we found many applications of the BCW approach used in healthcare. However, we found no accounts of stakeholders' experiences when the BCW approach was used with large groups of people who were mostly unfamiliar with behavioural science. Objective The goal of this research was to gain insight into the use of the BCW approach in the context of developing a framework to support deprescribing in long-term care. Methods This descriptive qualitative study employed one-on-one semi-structured interviews with Ontario long-term care stakeholders who had participated in one or both of two in-person forums that we hosted. Interviews were transcribed verbatim and an inductive content-analysis approach was used to code data and determine themes. Results Fifteen interviews were conducted. Four themes were identified. First, the BCW was new and made sense, but people found it hard to identify target behaviours before planning solutions. Second, participants varied in their opinions as to whether the 'right' people were participating. Third, participants found that the forum activities, worksheets and facilitators helped people use the approach. Fourth, stakeholder perspectives about potential implementation challenges and strategies to maximize success were identified. Conclusions Overall, participants were positive about the use of the BCW approach, however, its usefulness could be optimized by enhancing explanations, facilitation and logistics to ensure an initial focus on targeting behaviours. Making stakeholder perspectives transparent and ensuring mechanisms are present to ensure all views are sought and considered are also important to optimizing participant experience.
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Soni A, Thiyagarajan A, Reeve J. Feasibility and effectiveness of deprescribing benzodiazepines and Z-drugs: systematic review and meta-analysis. Addiction 2023; 118:7-16. [PMID: 35815384 DOI: 10.1111/add.15997] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 06/26/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS A total of 2.4 million adults in England were dispensed a benzodiazepine or Z-drug (BZRA) in 2017/18, and more than 250 000 patients in the UK take BZRAs beyond the recommended duration. Deprescribing is a clinician-guided process of withdrawing inappropriate drugs. This review aimed to evaluate the evidence base supporting the feasibility and clinical effectiveness of all forms of deprescribing initiatives used to discontinue long-term (≥ 4 weeks) BZRAs. METHOD Systematic review of randomized controlled trials evaluating BZRAs deprescribing among adults in community, primary or outpatient settings. MEDLINE, Embase and PsycINFO were searched from inception to February 2021. Primary outcomes were successful discontinuation in the short (< 4 weeks) or long term (≥ 4 weeks) and the occurrence of withdrawal symptoms, behavioural or psychological symptoms. Studies were categorized as pharmacological or non-pharmacological supported interventions. Study quality was assessed using the Cochrane risk-of-bias tool. Where appropriate, risk ratios (RRs), mean differences and 95% confidence intervals (CIs) were calculated, and Mantel-Haenszel methods using the random-effect meta-analysis was undertaken to calculate summary effect estimates. RESULTS Ten studies were included (n = 1431 participants). Heterogeneity in study design and effect was observed. Benzodiazepines were successfully deprescribed when gradually tapered with non-pharmacological support compared with gradual tapering alone in the short term (n = 124; RR = 2.02; 95% CI = 1.41, 2.89) and long term (n = 123; RR = 2.45; 95% CI = 1.56, 3.85). Benzodiazepine deprescribing was more successful when supported by non-pharmacological methods versus routine care (n = 189; RR = 3.26; 95% CI = 2.36, 4.51). Quality of evidence reporting effectiveness was very low to low. CONCLUSIONS It may be feasible to deprescribe benzodiazepines depending on the process and support mechanisms employed.
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Affiliation(s)
- Anisha Soni
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Hull, UK
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Linsky AM, Kressin NR, Stolzmann K, Pendergast J, Rosen AK, Bokhour BG, Simon SR. Direct-to-consumer strategies to promote deprescribing in primary care: a pilot study. BMC PRIMARY CARE 2022; 23:53. [PMID: 35317734 PMCID: PMC8939089 DOI: 10.1186/s12875-022-01655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022]
Abstract
Background Deprescribing, or the intentional discontinuation or dose-reduction of medications, is an approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications. Methods We conducted a pre-post pilot trial, using an historical control group, at an urban VA medical center. We included patients in one of two cohorts: 1) chronic proton pump inhibitor users (PPI), defined as use of any dose for 90 consecutive days, or 2) patients at hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c < 7%; and age ≥ 65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome. Results The 348 subjects (253 intervention, 95 historical control) were primarily age ≥ 65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p = 0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p = 0.001). Conclusions Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method associated with increases in both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the potential for patients to initiate deprescribing discussions within clinical encounters is a promising strategy to reduce drug burden and decrease adverse drug effects and harms.
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Sheppard JP, Benetos A, McManus RJ. Antihypertensive Deprescribing in Older Adults: a Practical Guide. Curr Hypertens Rep 2022; 24:571-580. [PMID: 35881225 PMCID: PMC9568439 DOI: 10.1007/s11906-022-01215-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To summarise evidence on both appropriate and inappropriate antihypertensive drug withdrawal. RECENT FINDINGS Deprescribing should be attempted in the following steps: (1) identify patients with several comorbidities and significant functional decline, i.e. people at higher risk for negative outcomes related to polypharmacy and lower blood pressure; (2) check blood pressure; (3) identify candidate drugs for deprescribing; (4) withdraw medications at 4-week intervals; (5) monitor blood pressure and check for adverse events. Although evidence is accumulating regarding short-term outcomes of antihypertensive deprescribing, long-term effects remain unclear. The limited evidence for antihypertensive deprescribing means that it should not be routinely attempted, unless in response to specific adverse events or following discussions between physicians and patients about the uncertain benefits and harms of the treatment. PERSPECTIVES Clinical controlled trials are needed to examine the long-term effects of deprescribing in older subjects, especially in those with comorbidities, and significant functional decline.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - Athanase Benetos
- Maladies du Vieillissement, Gérontologie Et Soins Palliatifs", and Inserm DCAC u1116, CHRU-Nancy, Université de Lorraine, 54000, PôleNancy, France
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
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Farrell B, Galley E, Jeffs L, Howell P, McCarthy LM. “Kind of blurry”: Deciphering clues to prevent, investigate and manage prescribing cascades. PLoS One 2022; 17:e0272418. [PMID: 36044402 PMCID: PMC9432713 DOI: 10.1371/journal.pone.0272418] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/19/2022] [Indexed: 11/19/2022] Open
Abstract
Background Prescribing cascades, where a medication is used to treat the side effect of another medication, contribute to polypharmacy and related morbidity. Little is known about clinicians’ and patients’ experiences with prescribing cascades. In this study, we explored why and how prescribing cascades occur across a variety of care settings and how they are managed. Methods and findings This descriptive qualitative study employed semi-structured interviews with older adults who may have experienced a prescribing cascade(s), their caregivers, and healthcare providers. Interviewees were recruited through physician referral from a Geriatric Day Hospital, two long-term care homes in Ottawa, Ontario, and through self-referral across Ontario, Canada. An inductive approach was used to code data and determine themes. Thirty-one interviews were conducted for ten unique patient cases. Some interviewees were involved in more than one case, resulting in 22 unique interviewees. Three themes were identified. First, recognition of prescribing cascades is linked to awareness of medication side effects. Second, investigation and management of prescribing cascades is simultaneous and iterative (rather than linear and sequential). Third, prevention of prescribing cascades requires intentional strategies to help people anticipate and recognize medication side effects. Difficulty with recruitment from both long-term care homes and through self-referral was the central limitation. This exemplifies challenges associated with studying a poorly recognized and underexplored phenomenon. Conclusions In order to better recognize, investigate and manage prescribing cascades, clinicians and patients need to know more about medication side effects; they need to ask ‘can this be caused by a drug?’ when signs and symptoms arise or worsen; and they need access to information about medication experiences to have benefit-risk discussions and make decisions about deprescribing. Approaches for raising public awareness of prescribing cascades should be trialed to raise the profile of this issue and facilitate continued exploration of the phenomenon.
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Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Emily Galley
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lianne Jeffs
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Pam Howell
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lisa M. McCarthy
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Leslie Dan Faculty of Pharmacy and Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Toronto, Ontario, Canada
- * E-mail:
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Bai I, Isenor JE, Reeve E, Whelan AM, Martin-Misener R, Burgess S, Kennie-Kaulbach N. Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs. Res Social Adm Pharm 2021; 18:3350-3357. [PMID: 34895842 DOI: 10.1016/j.sapharm.2021.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. OBJECTIVES To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. METHODS Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. RESULTS Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. CONCLUSIONS This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.
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Affiliation(s)
- Isaac Bai
- Faculty of Medicine, Dalhousie University, 5849 University Ave, Halifax, NS, Canada
| | - Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and 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
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
| | - Sarah Burgess
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
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Zakerabasali S, Ayyoubzadeh SM, Baniasadi T, Yazdani A, Abhari S. Mobile Health Technology and Healthcare Providers: Systemic Barriers to Adoption. Healthc Inform Res 2021; 27:267-278. [PMID: 34788907 PMCID: PMC8654335 DOI: 10.4258/hir.2021.27.4.267] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives Despite the growing use of mobile health (mHealth), certain barriers seem to be hindering the use of mHealth applications in healthcare. This article presents a systematic review of the literature on barriers associated with mHealth reported by healthcare professionals. Methods This systematic review was carried out to identify studies published from January 2015 to December 2019 by searching four electronic databases (PubMed/MEDLINE, Web of Science, Embase, and Google Scholar). Studies were included if they reported perceived barriers to the adoption of mHealth from healthcare providers’ perspectives. Content analysis and categorization of barriers were performed based on a focus group discussion that explored researchers’ knowledge and experiences. Results Among the 273 papers retrieved through the search strategy, 18 works were selected and 18 barriers were identified. The relevant barriers were categorized into three main groups: technical, individual, and healthcare system. Security and privacy concerns from the category of technical barriers, knowledge and limited literacy from the category of individual barriers, and economic and financial factors from the category of healthcare system barriers were chosen as three of the most important challenges related to the adoption of mHealth described in the included publications. Conclusions mHealth adoption is a complex and multi-dimensional process that is widely implemented to increase access to healthcare services. However, it is influenced by various factors and barriers. Understanding the barriers to adoption of mHealth applications among providers, and engaging them in the adoption process will be important for the successful deployment of these applications.
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Affiliation(s)
- Somayyeh Zakerabasali
- Clinical Education Research Center, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohammad Ayyoubzadeh
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Tayebeh Baniasadi
- Department of Health Information Technology, Faculty of Paramedicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Azita Yazdani
- Clinical Education Research Center, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahabeddin Abhari
- Amol Faculty of Paramedical Sciences, Mazandaran University of Medical Sciences, Sari, Iran
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Pruskowski JA, Jeffery SM, Brandt N, Zarowitz BJ, Handler SM. How to implement deprescribing into clinical practice. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jennifer A. Pruskowski
- Veterans Affairs Pittsburgh Healthcare System, Geriatric Research Education and Clinical Center Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sean M. Jeffery
- University of Connecticut School of Pharmacy Storrs Connecticut USA
| | - Nicole Brandt
- University of Maryland School of Pharmacy Baltimore Maryland USA
| | | | - Steven M. Handler
- Veterans Affairs Pittsburgh Healthcare System, Geriatric Research Education and Clinical Center Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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Zahn B, Reist J, Kennelty K, Casteel C, Shannon ZK, Niles M. Medication Management and Deprescribing in Assisted Living Facilities. Sr Care Pharm 2021; 36:439-443. [PMID: 34452653 DOI: 10.4140/tcp.n.2021.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Medication management for seniors is a foundation for keeping them healthy and independent. A vital aspect of medication management is the selective discontinuation of medications, or deprescribing. While this is a common practice within nursing homes it seems to be less common among those who live in assisted living facilities. Shockingly little exiting literature was found when conducting a literature review concerning deprescribing in assisted living facilities. Therefore, it was determined to set forth this call to action to focus on deprescribing in assisted living facilities hoping that it would be given more attention to keep our seniors healthy and safe.
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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15
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Mehta RS, Kochar BD, Kennelty K, Ernst ME, Chan AT. Emerging approaches to polypharmacy among older adults. NATURE AGING 2021; 1:347-356. [PMID: 37117591 DOI: 10.1038/s43587-021-00045-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/10/2021] [Indexed: 12/22/2022]
Abstract
Polypharmacy is a major health issue for older adults. Entangled with several geriatric syndromes, including frailty, falls and cognitive decline, research focused on polypharmacy has been challenged by heterogeneity in its definition, confounding by comorbidities and limited prospective data. In this Review, we discuss varying definitions for polypharmacy and highlight the need for a uniform definition for future studies. We critically appraise strategies for reducing medication prescriptions and implementing deprescribing as a mechanism to reduce the potential harmful effects of polypharmacy. As we look to the future, we assess the role of novel analytics and high-throughput technology, including multiomics profiling, to advance research in polypharmacy and the development of new strategies for risk stratification in the age of precision medicine.
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Affiliation(s)
- Raaj S Mehta
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bharati D Kochar
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Korey Kennelty
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, IA, USA
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, IA, USA
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Lau S, Lun P, Ang W, Tan KT, Ding YY. Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review. BMC Geriatr 2020; 20:459. [PMID: 33167898 PMCID: PMC7650160 DOI: 10.1186/s12877-020-01766-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. METHODS A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. RESULTS A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour. CONCLUSION The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
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Affiliation(s)
- Sabrina Lau
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Penny Lun
- Geriatric Education & Research Institute, Singapore, Singapore
| | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Keng Teng Tan
- Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- Geriatric Education & Research Institute, Singapore, Singapore
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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.
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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
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Kennie-Kaulbach N, Cormier R, Kits O, Reeve E, Whelan AM, Martin-Misener R, Burge F, Burgess S, Isenor JE. Influencers on deprescribing practice of primary healthcare providers in Nova Scotia: An examination using behavior change frameworks. MEDICINE ACCESS @ POINT OF CARE 2020; 4:2399202620922507. [PMID: 36204093 PMCID: PMC9413600 DOI: 10.1177/2399202620922507] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/08/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Deprescribing is a complex process requiring consideration of behavior change theory to improve implementation and uptake. Aim: The aim of this study was to describe the knowledge, attitudes, beliefs, and behaviors that influence deprescribing for primary healthcare providers (family physicians, nurse practitioners (NPs), and pharmacists) within Nova Scotia using the Theoretical Domains Framework version 2 (TDF(v2)) and the Behavior Change Wheel. Methods: Interviews and focus groups were completed with primary care providers (physicians, NPs, and pharmacists) in Nova Scotia, Canada. Coding was completed using the TDF(v2) to identify the key influencers. Subdomain themes were also identified for the main TDF(v2) domains and results were then linked to the Behavior Change Wheel—Capability, Opportunity, and Motivation components. Results: Participants identified key influencers for deprescribing including areas related to Opportunity, within TDF(v2) domain Social Influences, such as patients and other healthcare providers, as well as Physical barriers (TDF(v2) domain Environmental Context and Resources), such as lack of time and reimbursement. Conclusion: Our results suggest that a systematic approach to deprescribing in primary care should be supported by opportunities for patient and healthcare provider collaborations, as well as practice and system level enhancements to support sustainability of deprescribing practices.
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Affiliation(s)
- Natalie Kennie-Kaulbach
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | | | - Olga Kits
- Research Methods Unit, Research & Innovation, Nova Scotia Health Authority, Halifax, NS, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 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 & Nova Scotia Health Authority, Halifax, NS, Canada
| | | | | | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
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Sonmez A, Tasci I, Demirci I, Haymana C, Barcin C, Aydin H, Cetinkalp S, Ozturk FY, Gul K, Sabuncu T, Satman I, Bayram F. A Cross-Sectional Study of Overtreatment and Deintensification of Antidiabetic and Antihypertensive Medications in Diabetes Mellitus: The TEMD Overtreatment Study. Diabetes Ther 2020; 11:1045-1059. [PMID: 32088879 PMCID: PMC7193034 DOI: 10.1007/s13300-020-00779-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians' attitudes to deintensify or intensify treatment. METHODS Data from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s). RESULTS The rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2-3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0-3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14-3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP. CONCLUSIONS The results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03455101.
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Affiliation(s)
- Alper Sonmez
- Department of Endocrinology and Metabolism, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Ilker Tasci
- Department of Internal Medicine, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ibrahim Demirci
- Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Cem Haymana
- Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Cem Barcin
- Department of Cardiology, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Hasan Aydin
- Department of Endocrinology and Metabolism, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Sevki Cetinkalp
- Department of Endocrinology and Metabolism, School of Medicine, Ege University, Izmir, Turkey
| | - Feyza Yener Ozturk
- Department of Endocrinology and Metabolism, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Kamile Gul
- Department of Endocrinology and Metabolism, School of Medicine, Sutcu Imam University, Kahramanmaras, Turkey
| | - Tevfik Sabuncu
- Department of Endocrinology and Metabolism, School of Medicine, Harran University, Sanliurfa, Turkey
| | - Ilhan Satman
- Department of Endocrinology and Metabolism, School of Medicine, Istanbul University, Istanbul, Turkey
| | - Fahri Bayram
- Department of Endocrinology and Metabolism, School of Medicine, Erciyes University, Kayseri, Turkey
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Langford AV, Gnjidic D, Lin CWC, Bero L, Penm J, Blyth FM, Schneider CR. Challenges of opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines: a qualitative analysis. BMJ Qual Saf 2020; 30:133-140. [PMID: 32220937 DOI: 10.1136/bmjqs-2020-010881] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines. METHODS A qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective. RESULTS Healthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques. CONCLUSION Opioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.
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Affiliation(s)
- Aili V Langford
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Bero
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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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.
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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
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