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Schuster BG, Faisal S, L Gagnon C. A new curricular framework for an interprofessional approach to deprescribing: Why and how pharmacists should lead the way. Can Pharm J (Ott) 2024; 157:101-103. [PMID: 38737361 PMCID: PMC11086733 DOI: 10.1177/17151635241239924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/09/2023] [Indexed: 05/14/2024]
Affiliation(s)
| | - Sadaf Faisal
- Research Centre, Institut universitaire de gériatrie de Montréal
| | - Camille L Gagnon
- Research Centre, Institut universitaire de gériatrie de Montréal
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Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
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3
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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4
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Ashkanani FZ, Rathbone AP, Lindsey L. The role of pharmacists in deprescribing benzodiazepines: A scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100328. [PMID: 37743854 PMCID: PMC10511800 DOI: 10.1016/j.rcsop.2023.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
Background Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines. Method A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English. Results Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing. Conclusion Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.
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Affiliation(s)
- Fatemah Zakariya Ashkanani
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Adam Pattison Rathbone
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Laura Lindsey
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
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Price E, Shirtcliffe A, Fisher T, Chadwick M, Marra CA. A systematic review of economic evaluations of pharmacist services. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:459-471. [PMID: 37543960 DOI: 10.1093/ijpp/riad052] [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: 01/04/2023] [Accepted: 07/07/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Challenges to the provision of health care are occurring internationally and are expected to increase in the future, further increasing health spending. As pharmacist roles are evolving and expanding internationally to provide individualised pharmaceutical care it is important to assess the cost-effectiveness of these services. OBJECTIVES To systematically synthesise the international literature regarding published economic evaluations of pharmacy services to assess their cost-effectiveness and clinical outcomes. METHODS A systematic review of economic evaluations of pharmacy services was conducted in MEDLINE, EMBASE, PubMed, Scopus, Web of Science, CINAHL, IPA and online journals with search functions likely to publish economic evaluations of pharmacy services. Data were extracted regarding the interventions, the time horizon, the outcomes and the incremental cost-effectiveness ratio. Studies' quality of reporting was assessed using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) statement. RESULTS Seventy-five studies were included in the systematic review, including 67 cost-effectiveness analyses, 6 cost-benefit analyses and 2 cost-consequence analyses. Of these, 57 were either dominant or cost-effective using a willingness-to-pay threshold of NZ$46 645 per QALY. A further 11 studies' cost-effectiveness were unable to be evaluated. Interventions considered to be most cost-effective included pharmacist medication reviews, pharmacist adherence strategies and pharmacist management of type 2 diabetes mellitus, hypertension and warfarin/INR monitoring. The quality of reporting of studies differed with no studies reporting all 28 items of the CHEERS statement. CONCLUSIONS There is strong economic evidence to support investment in extended pharmacist services, particularly those focussed on long-term chronic health conditions.
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Affiliation(s)
- Emilia Price
- Division of Health Sciences, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Andi Shirtcliffe
- Allied Health Office of the Chief Clinical Officers System Performance and Monitoring Ministry of Health, Wellington, New Zealand
| | - Thelma Fisher
- Centre for Pacific Health Information Services, University Library, University of Otago, Dunedin, New Zealand
| | - Martin Chadwick
- Office of the Chief Clinical Officers, Ministry of Health, Wellington, New Zealand
| | - Carlo A Marra
- Division of Health Sciences, School of Pharmacy, University of Otago, Dunedin, New Zealand
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Farrell B, Raman-Wilms L, Sadowski CA, Mallery L, Turner J, Gagnon C, Cole M, Grill A, Isenor JE, Mangin D, McCarthy LM, Schuster B, Sirois C, Sun W, Upshur R. A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing. MEDICAL SCIENCE EDUCATOR 2023; 33:551-567. [PMID: 37261023 PMCID: PMC10226933 DOI: 10.1007/s40670-022-01704-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 06/02/2023]
Abstract
Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-022-01704-9.
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Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, 43 Bruyère St, Ottawa, ON K1N 5C8 Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
- Centre On Aging, Winnipeg, MB Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada
| | - Laurie Mallery
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Justin Turner
- Faculty of Pharmacy, University of Montreal, Montreal, QC Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Camille Gagnon
- Canadian Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC Canada
| | - Mollie Cole
- Canadian Gerontological Nursing Association, Calgary, AB Canada
| | - Allan Grill
- Dept. of Family & Community Medicine, University of Toronto, Toronto, ON Canada
- Markham Family Health Team, Markham, ON Canada
- Ontario Renal Network, Toronto, Canada
| | - Jennifer E. Isenor
- College of Pharmacy, Faculty of Health and Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Dee Mangin
- David Braley & Nancy Gordon Chair in Family Medicine, Department of Family Medicine, McMaster University, Hamilton, ON Canada
- Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Lisa M. McCarthy
- Bruyère Research Institute, 43 Bruyère St, Ottawa, ON K1N 5C8 Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON Canada
- Institute for Better Health and Pharmacy Department, Trillium Health Partners, Mississauga, ON Canada
- Leslie Dan Faculty of Pharmacy & Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
- Women’s College Research Institute, Toronto, ON Canada
| | - Brenda Schuster
- College of Medicine (Regina Campus), University of Saskatchewan, Regina, Saskachewan Canada
| | - Caroline Sirois
- Centre d’excellence Sur Le Vieillissement de Québec & VITAM - Research Centre On Sustainable Health, Québec, Canada
- Faculty of Pharmacy, Université Laval, Québec, Canada
| | - Winnie Sun
- Faculty of Health Sciences, Ontario Tech University, Oshawa, ON Canada
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Bridgepoint Collaboratory for Research and Innovation, Toronto, ON Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health, Toronto, ON Canada
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
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7
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Hu Y, Huerta J, Cordella N, Mishuris RG, Paschalidis IC. Personalized hypertension treatment recommendations by a data-driven model. BMC Med Inform Decis Mak 2023; 23:44. [PMID: 36859187 PMCID: PMC9979505 DOI: 10.1186/s12911-023-02137-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Hypertension is a prevalent cardiovascular disease with severe longer-term implications. Conventional management based on clinical guidelines does not facilitate personalized treatment that accounts for a richer set of patient characteristics. METHODS Records from 1/1/2012 to 1/1/2020 at the Boston Medical Center were used, selecting patients with either a hypertension diagnosis or meeting diagnostic criteria (≥ 130 mmHg systolic or ≥ 90 mmHg diastolic, n = 42,752). Models were developed to recommend a class of antihypertensive medications for each patient based on their characteristics. Regression immunized against outliers was combined with a nearest neighbor approach to associate with each patient an affinity group of other patients. This group was then used to make predictions of future Systolic Blood Pressure (SBP) under each prescription type. For each patient, we leveraged these predictions to select the class of medication that minimized their future predicted SBP. RESULTS The proposed model, built with a distributionally robust learning procedure, leads to a reduction of 14.28 mmHg in SBP, on average. This reduction is 70.30% larger than the reduction achieved by the standard-of-care and 7.08% better than the corresponding reduction achieved by the 2nd best model which uses ordinary least squares regression. All derived models outperform following the previous prescription or the current ground truth prescription in the record. We randomly sampled and manually reviewed 350 patient records; 87.71% of these model-generated prescription recommendations passed a sanity check by clinicians. CONCLUSION Our data-driven approach for personalized hypertension treatment yielded significant improvement compared to the standard-of-care. The model implied potential benefits of computationally deprescribing and can support situations with clinical equipoise.
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Affiliation(s)
- Yang Hu
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA
| | - Jasmine Huerta
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Nicholas Cordella
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Ioannis Ch Paschalidis
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
- Department of Biomedical Engineering, Faculty of Computing & Data Sciences, Hariri Institute for Computing and Computational Science & Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
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Dawson KG, Mok V, Wong JG, Bhalla A. Deprescribing initiative of NSAIDs (DIN): Pharmacist-led interventions for pain management in a federal correctional setting. Can Pharm J (Ott) 2023; 156:85-93. [PMID: 36969304 PMCID: PMC10034525 DOI: 10.1177/17151635221149712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for management of pain and inflammation. However, these medications are associated with adverse outcomes such as dyspepsia and acute myocardial infarction, especially with long-term uses. Objective: We sought to determine the effect of a pharmacist-led deprescribing intervention on oral NSAID use among patients in federal custody. Methods: Clinical pharmacists from Correctional Services Canada (CSC) conducted a prospective case series of adult patients with chronic noncancer pain who were on long-term NSAIDs (defined as >90 days supply in the past 120 days) in 3 CSC institutions in British Columbia, Canada. CSC clinical pharmacists met with patients to perform medication reviews and identify drug-related problems, with a focus on analgesic therapy. Pharmacist-led interventions were implemented in consultation with the primary care team to address these drug-related problems. Patient progress was monitored weekly for 3 months. Function, quality of life and pain severity scores (modified SPAASMS, Patient-Specific Functional Scale [PSFS] and visual analog scale [VAS] scores) were compared at baseline, 6 weeks and 3 months postintervention. Patient satisfaction survey results were also collected at 3 months. Results: A total of 53 patients received clinical pharmacist interventions. Modified SPAASMS, PSFS and VAS scores were collected at baseline, 6 weeks and 3 months from 38 patients (some were lost to follow-up when released back into the community). All 38 patients demonstrated clinically significant improvements to all 3 pain scales at 3 months (mean SPAASMS scores decreased by 7 points, mean PSFS scores increased by 2 points, mean VAS scores decreased by 2 points). Twenty-four of 31 patients who completed the patient satisfaction survey agreed that their overall health and well-being improved because of the visit they received from the pharmacist. Conclusion: Clinical pharmacist-led interventions in CSC have shown to reduce oral NSAID use as well as contribute positively to patient pain scores.
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Affiliation(s)
| | - Vanessa Mok
- Pacific Regional Hospital Pharmacy, Abbotsford, British Columbia
| | - Jason G.M. Wong
- Pacific Regional Hospital Pharmacy, Abbotsford, British Columbia
| | - Alka Bhalla
- Correctional Service Canada, National Headquarters, Ottawa, Ontario
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9
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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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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11
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Desai M, Park T. Deprescribing practices in Canada: A scoping review. Can Pharm J (Ott) 2022; 155:249-257. [PMID: 36081917 PMCID: PMC9445505 DOI: 10.1177/17151635221114114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Background: Excessive and inappropriate use of medications, defined as polypharmacy, can increase the risk of adverse drug reactions while affecting patient adherence and quality of life. Therefore, optimizing pharmacotherapies through deprescribing practices plays a crucial role in managing chronic conditions, avoiding adverse effects and improving patient outcomes. The purpose of this study was to explore research initiatives surrounding deprescribing in Canada. Methods: A scoping review was conducted that involved a search of 6 databases. Studies that highlighted deprescribing interventions, experiences and other effects on Canadian populations were included. Results: Searches yielded 2327 citations, of which 31 were included in this review. Five major themes and ideas were identified: deprescribing targeted medications, financial effects of deprescribing, deprescribing in special populations, insight from health care providers and deprescribing frameworks. Conclusion: Deprescribing practices in Canada have shown a wide range of beneficial results across various health care settings, populations and medication classes and have the potential to reduce medication-related harm in all Canadian health care settings.
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12
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Rantsi M, Pitkälä KH, Kautiainen H, Hyttinen V, Kankaanpää E. Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication. Age Ageing 2022; 51:6590511. [PMID: 35604803 PMCID: PMC9126199 DOI: 10.1093/ageing/afac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). Methods The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period. Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. Results The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY. Conclusion The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.
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Affiliation(s)
- Mervi Rantsi
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Kaisu H Pitkälä
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Hannu Kautiainen
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Eila Kankaanpää
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
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13
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Fuertes Abardía C, Ballesta Juan P, Cruz Esteve I, Galindo Ortego G, Marsal Mora JR, Gómez-Arbonés X. [Potentially inappropriate prescribing: Usefulness of STOPP/START criteria version 2 in Catalonian elderly population]. Semergen 2022; 48:163-173. [PMID: 35151557 DOI: 10.1016/j.semerg.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/03/2021] [Accepted: 09/11/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To measure the prevalence of potentially inappropriate prescribing (PIP) among the elderly population in Catalonia using criteria Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) version 2. In addition, to evaluate the association between PIP and several factors (polypharmacy, gender, age and sociodemographic conditions). MATERIALS AND METHODS Design: Retrospective cross sectional population study. SETTINGS Primary Health Care, Catalonia, Spain. PARTICIPANTS The study population comprised of participants 70 years old and over, who attended primary health care centres in Catalonia in 2014 (700.058 patients). MAIN ANALYSIS 55 STOPP and 19 START criteria are applied to analyse PIP prevalence. Logistic regression models are adjusted to determine PIP association with several factors. RESULTS The mean age is 79. 2±6.5. 58.5% being female. 38.7% of patients have 7 or more prescribed drugs, whereas 50% go to a primary care centre 10 or more times during one year. The most frequent PIP among STOPP criteria are related to nonsteroidal anti-inflammatory drug intake, antiplatelet and anticoagulants use, and benzodiazepines. According to START, the most frequent omissions are vitamin D and calcium supplements, antidepressants, and cardiovascular medications. Factors that increase PIP are: female gender, living in a nursing home, receiving home health care, polypharmacy and frequent visits to primary care centres. CONCLUSIONS The overall prevalence of PIP is 89.6%. PPI is significantly related to certain drugs and patient's conditions. The knowledge of this association is important for the implementation of security measures for medical prescription.
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Affiliation(s)
- C Fuertes Abardía
- Centro de Atención Primaria Primer de Maig, Institut Català de la Salut, Lleida, España.
| | - P Ballesta Juan
- Centro de Salud Elx Carrús Este, Departamento de Salud del Vinalopó, Elche, España
| | - I Cruz Esteve
- Centro de Atención Primaria Primer de Maig, Institut Català de la Salut, Lleida, España
| | - G Galindo Ortego
- Centro de Atención Primaria Primer de Maig, Institut Català de la Salut, Lleida, España
| | - J R Marsal Mora
- Unitat de Suport a la Recerca Lleida-Pirineus, Institut d'Investigació en Atenció Primària J Gol (IDIAP J Gol), Lleida, España
| | - X Gómez-Arbonés
- Departamento de Medicina, Universitat de Lleida, Lleida, España; Institut de Recerca Biomèdica de Lleida (IRB Lleida), Lleida, España
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14
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Jowett S, Kodabuckus S, Ford GA, Hobbs FDR, Lown M, Mant J, Payne R, McManus RJ, Sheppard JP. Cost-Effectiveness of Antihypertensive Deprescribing in Primary Care: a Markov Modelling Study Using Data From the OPTiMISE Trial. Hypertension 2022; 79:1122-1131. [PMID: 35266409 PMCID: PMC8997697 DOI: 10.1161/hypertensionaha.121.18726] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deprescribing of antihypertensive medications for older patients with normal blood pressure is recommended by some clinical guidelines, where the potential harms of treatment may outweigh the benefits. This study aimed to assess the cost-effectiveness of this approach. METHODS A Markov patient-level simulation was undertaken to model the effect of withdrawing one antihypertensive compared with usual care, over a life-time horizon. Model population characteristics were estimated using data from the OPTiMISE antihypertensive deprescribing trial, and the effects of blood pressure changes on outcomes were derived from the literature. Health-related quality of life was modeled in Quality-Adjusted Life Years (QALYs) and presented as costs per QALY gained. RESULTS In the base-case analysis, medication reduction resulted in lower costs than usual care (mean difference £185), but also lower QALYs (mean difference 0.062) per patient over a life-time horizon. Usual care was cost-effective at £2975 per QALY gained (more costly, but more effective). Medication reduction resulted more heart failure and stroke/TIA events but fewer adverse events. Medication reduction may be the preferred strategy at a willingness-to-pay of £20 000/QALY, where the baseline absolute risk of serious drug-related adverse events was ≥7.7% a year (compared with 1.7% in the base-case). CONCLUSIONS Although there was uncertainty around many of the assumptions underpinning this model, these findings suggest that antihypertensive medication reduction should not be attempted in many older patients with controlled systolic blood pressure. For populations at high risk of adverse effects, deprescribing may be beneficial, but a targeted approach would be required in routine practice.
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Affiliation(s)
- Sue Jowett
- Institute of Applied Health Research, University of Birmingham, United Kingdom (S.J., S.K.)
| | - Shahela Kodabuckus
- Institute of Applied Health Research, University of Birmingham, United Kingdom (S.J., S.K.)
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and University of Oxford, United Kingdom (G.A.F.)
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (F.D.R.H., R.J.M., J.P.S.)
| | - Mark Lown
- Primary Care Research Centre, University of Southampton, Southampton, United Kingdom (M.L.)
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, United Kingdom (J.M.)
| | - Rupert Payne
- Population Health Sciences, University of Bristol, United Kingdom (R.P.)
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (F.D.R.H., R.J.M., J.P.S.)
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (F.D.R.H., R.J.M., J.P.S.)
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15
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Jayesinghe R, Moriarty F, Khatter A, Durbaba S, Ashworth M, Redmond P. Cost Outcomes of Potentially Inappropriate Prescribing (PIP) in Middle-Aged Adults: A Delphi consensus and Cross-sectional Study. Br J Clin Pharmacol 2022; 88:3404-3420. [PMID: 35244286 DOI: 10.1111/bcp.15295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Potentially inappropriate prescribing (PIP) is common in older adults and is associated with increased medication costs and costs of associated adverse drug events (ADE). PIP also affects almost one-fifth of middle-aged adults (45-64 years old), as defined by the PRescribing Optimally in Middle-aged People's Treatments (PROMPT) criteria. However, there has been little research on PIP medication costs within this age group. AIMS Calculate the medication costs of PIP for middle-aged adults according to the 22 PROMPT criteria and compare with the cost of consensus-validated, evidence-based ('adequate') alternative prescribing scenarios. METHODOLOGY Adequate alternatives to the 22 PROMPT criteria were created via literature review. A Delphi consensus panel of experts were recruited (n=16), supported by a patient and public involvement group, to achieve consensus on the alternatives. A retrospective repeated cross-sectional study from 2014 to 2019 was then conducted utilising pseudonymised primary care data from Lambeth DataNet in South London (41 general practices, N=1,185,335, using LDN May 2020 extract) to calculate the cost of PIP. RESULTS The cross-sectional study included 55,880 patients. The total PIP cost was £2.79 million, with adequate alternative prescribing costing £2.74 million (cost savings of £51,278). Duplicate drug classes was the most costly criterion for both PIP and alternative prescribing. CONCLUSIONS This study calculated the medication costs of PIP and created alternative prescribing scenarios for the 22 PROMPT criteria. There is no substantial cost difference between adequate prescribing versus PIP. Future studies should investigate the wider health economic costs of alternative prescribing, such as reducing hospital admissions.
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Affiliation(s)
- Ryan Jayesinghe
- School of Life Course & Population Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Amandeep Khatter
- School of Life Course & Population Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Stevo Durbaba
- School of Life Course & Population Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Mark Ashworth
- School of Life Course & Population Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Patrick Redmond
- School of Life Course & Population Sciences, King's College London, Guy's Campus, King's College London, London, UK.,Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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16
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Romano S, Figueira D, Teixeira I, Perelman J. Deprescribing Interventions among Community-Dwelling Older Adults: A Systematic Review of Economic Evaluations. PHARMACOECONOMICS 2022; 40:269-295. [PMID: 34913143 DOI: 10.1007/s40273-021-01120-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Deprescribing can reduce the use of inappropriate or unnecessary medication; however, the economic value of such interventions is uncertain. OBJECTIVE This study seeks to identify and synthetise the economic evidence of deprescribing interventions among community-dwelling older adults. METHODS Full economic evaluation studies of deprescribing interventions, conducted in the community or primary care settings, in community-dwelling adults aged ≥ 65 years were systematically reviewed. MEDLINE, EconLit, Scopus, Web of Science, CEA-TUFTS, CRD York and Google Scholar databases were searched from inception to February 2021. Two researchers independently screened all retrieved articles according to inclusion and exclusion criteria. The main outcome was the economic impact of the intervention from any perspective, converted into 2019 US Dollars. The World Health Organization threshold of 1 gross domestic product per capita was used to define cost effectiveness. Studies were appraised for methodological quality using the extended Consensus on Health Economics Criteria checklist. RESULTS Of 6154 articles identified by the search strategy, 14 papers assessing 13 different interventions were included. Most deprescribing interventions included some type of medication review with or without a supportive educational component (n = 11, 85%), and in general were delivered within a pharmacist-physician care collaboration. Settings included community pharmacies, primary care/outpatient clinics and patients' homes. All economic evaluations were conducted within a time horizon varying from 2 to 12 months with outcomes in most of the studies derived from a single clinical trial. Main health outcomes were reported in terms of quality-adjusted life-years, prevented number of falls and the medication appropriateness index. Cost effectiveness ranged from dominant to an incremental cost-effectiveness ratio of $112,932 per quality-adjusted life-year, a value above the country's World Health Organization threshold. Overall, 85% of the interventions were cost saving, dominated usual care or were cost effective considering 1 gross domestic product per capita. Nine studies scored > 80% (good) and two scored ≤ 50% (low) on critical quality appraisal. CONCLUSIONS There is a growing interest in economic evaluations of deprescribing interventions focused on community-dwelling older adults. Although results varied across setting, time horizon and intervention, most were cost effective according to the World Health Organization threshold. Deprescribing interventions are promising from an economic viewpoint, but more studies are needed.
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Affiliation(s)
- Sónia Romano
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal.
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Débora Figueira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Inês Teixeira
- Centre for Health Evaluation and Research/Infosaúde, National Association of Pharmacies (CEFAR-IF/ANF), Rua Marechal Saldanha 1, 1249-069, Lisbon, Portugal
| | - Julian Perelman
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Lisbon, Portugal
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17
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Mehuys E, De Backer T, De Keyser F, Christiaens T, Van Hees T, Demarche S, Van Tongelen I, Boussery K. PREVALENCE AND MANAGEMENT OF DRUG INTERACTIONS BETWEEN NSAID AND ANTITHROMBOTICS IN AMBULATORY CARE. Br J Clin Pharmacol 2022; 88:3896-3902. [DOI: 10.1111/bcp.15288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences Ghent University Ghent Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Centre Ghent University Hospital, Ghent, Belgium; and Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University Ghent Belgium
| | - Filip De Keyser
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Rheumatology Ghent University Hospital, Ghent, Belgium and praktijk10A Maldegem Belgium
| | | | | | | | - Inge Van Tongelen
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences Ghent University Ghent Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences Ghent University Ghent Belgium
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18
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Osae SP, Chastain DB, Young HN. Pharmacist role in addressing health disparities—Part 2: Strategies to move toward health equity. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1594] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sharmon P. Osae
- College of Pharmacy University of Georgia Albany Georgia USA
| | | | - Henry N. Young
- College of Pharmacy University of Georgia Athens Georgia USA
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19
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Rana R, Choi J, Vordenberg SE. Older adults’ willingness to consider deprescribing when experiencing hyperpolypharmacy. J Am Pharm Assoc (2003) 2022; 62:1189-1196. [DOI: 10.1016/j.japh.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
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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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Characterising risk of non-steroidal-anti-inflammatory drug related acute kidney injury: a retrospective cohort study. BJGP Open 2021; 6:BJGPO.2021.0208. [PMID: 34732389 PMCID: PMC8958739 DOI: 10.3399/bjgpo.2021.0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pain and inflammation. NSAID complications include acute kidney injury (AKI), causing burden to patients and health services through increased morbidity, mortality, and hospital admissions. AIM This study aimed to measure the extent of NSAID prescribing in an adult population, the degree to which patients with potential higher risk of AKI were exposed to NSAIDs, and to quantify their risk of AKI. DESIGN & SETTING Retrospective two-year closed-cohort study. METHOD A retrospective cohort of adults was identified from a pseudonymised electronic primary care database in Hampshire, UK. The cohort had clinical information, prescribing data and complete GP- and hospital- ordered biochemistry data. NSAID exposure (minimum one prescription in a two-month period) was categorised as never, intermittent and continuous, and first AKI using the national AKI eAlert algorithm. Descriptive statistics and logistic regression were used to explore NSAID prescribing patterns and AKI risk. RESULTS The baseline population was 702,265. NSAID prescription fell from 19,364 (2.8%) to 16,251 (2.4%) over two years. NSAID prescribing was positively associated with older age, women, greater socioeconomic deprivation, and certain comorbidities (diabetes, hypertension, osteoarthritis and rheumatoid arthritis) and negatively with cardiovascular disease (CVD) and heart failure. Among those prescribed NSAIDs, AKI was associated with older age, greater deprivation, CKD, CVD, heart failure, diabetes, and hypertension. CONCLUSIONS Despite generally good prescribing practice, we identified NSAID prescribing in some people at higher risk of AKI (CKD, older people) for whom medication review and NSAID de-prescribing should be considered.
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Roux B, Bezin J, Morival C, Noize P, Laroche ML. Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study. Expert Rev Pharmacoecon Outcomes Res 2021; 22:627-636. [PMID: 34525899 DOI: 10.1080/14737167.2021.1981863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France. METHODS A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population. RESULTS The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million). CONCLUSIONS PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
| | - Julien Bezin
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Camille Morival
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Pernelle Noize
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1219, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Laboratoire Vie-Santé (Vieillissement Fragilité Prévention, e-Santé), IFR GEIST, Université de Limoges, Limoges, France
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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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Trenaman SC, Bowles SK, Kirkland SA, Andrew MK. Potentially Inappropriate Drug Duplication in a Cohort of Older Adults with Dementia. CURRENT THERAPEUTIC RESEARCH 2021; 95:100644. [PMID: 34589160 PMCID: PMC8458971 DOI: 10.1016/j.curtheres.2021.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Concurrent use of 2 nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, loop diuretics, angiotensin-converting enzyme inhibitors, or anticoagulants is considered potentially inappropriate by Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment criteria. OBJECTIVE The objective was to examine drug duplication in a cohort of older adults with dementia. METHODS Cohort entry for Nova Scotia Seniors' Pharmacare Program beneficiaries was the date an International Classification of Diseases ninth edition or 10th edition code for dementia was recorded in accessed databases between March 1, 2005, and March 31, 2015. Medication dispensation and sociodemographic data were captured from the Nova Scotia Seniors' Pharmacare Program database between April 1, 2010, and March 31, 2015. Duplication was considered when 2 drugs from the same class were dispensed such that the supply in the patient's possession could overlap for more than 30 days. We reported number of cases of duplication and duration of overlap. Sex differences in drug duplication were assessed with bivariate logistic regression. RESULTS In the cohort of 28,953 Nova Scotia Seniors' Pharmacare Program beneficiaries with dementia, we documented concurrent use in 101 (1.7%) nonsteroidal anti-inflammatory drugs users (mean duration = 75.6 days), 95 (1.0%) selective serotonin reuptake inhibitors users (mean duration = 146.6 days), 5 (0.07%) loop diuretic users (mean duration = 530.6 days), 183 (2.0%) angiotensin-converting enzyme inhibitor users (mean duration = 123.9 days), and 160 (3.5%) anticoagulant users (mean duration = 63.6 days). Nonsteroidal anti-inflammatory drug pairs were most commonly celecoxib with naproxen or diclofenac. Selective serotonin reuptake inhibitors duplication was most commonly sertraline with citalopram. No sex differences in risk for drug duplication were identified. CONCLUSIONS Drug duplication was identified in a cohort of older adults with dementia and is a feasible target for intervention. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).
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Affiliation(s)
- Shanna C. Trenaman
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan K. Bowles
- Nova Scotia Health, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Susan A. Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa K. Andrew
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
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Bužančić I, Kummer I, Držaić M, Ortner Hadžiabdić M. Community-based pharmacists' role in deprescribing: A systematic review. Br J Clin Pharmacol 2021; 88:452-463. [PMID: 34155673 DOI: 10.1111/bcp.14947] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/15/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS Community-based pharmacists are an important stakeholder in providing continuing care for chronic multi-morbid patients, and their role is steadily expanding. The aim of this study is to examine the literature exploring community-based pharmacist-initiated and/or -led deprescribing and to evaluate the impact on the success of deprescribing and clinical outcomes. METHODS Library and clinical trials databases were searched from inception to March 2020. Studies were included if they explored deprescribing in adults, by community-based pharmacists and were available in English. Two reviewers extracted data independently using a pre-agreed data extraction template. Meta-analysis was not performed due to heterogeneity of study designs, types of intervention and outcomes. RESULTS A total of 24 studies were included in the review. Results were grouped based on intervention method into four categories: educational interventions; interventions involving medication review, consultation or therapy management; pre-defined pharmacist-led deprescribing interventions; and pharmacist-led collaborative interventions. All types of interventions resulted in greater discontinuation of medications in comparison to usual care. Educational interventions reported financial benefits as well. Medication review by community-based pharmacist can lead to successful deprescribing of high-risk medication, but do not affect the risk or rate of falls, rate of hospitalisations, mortality or quality of life. Pharmacist-led medication review, in patients with mental illness, resulting in deprescribing improves anticholinergic side effects, memory and quality of life. Pre-defined pharmacist-led deprescribing did not reduce healthcare resource consumptions but can contribute to financial savings. Short follow-up periods prevent evaluation of long-term sustainability of deprescribing interventions. CONCLUSION This systematic review suggests community-based pharmacists can lead deprescribing interventions and that they are valuable partners in deprescribing collaborations, providing necessary monitoring throughout tapering and post-follow-up to ensure the success of an intervention.
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Affiliation(s)
- Iva Bužančić
- City Pharmacies Zagreb, Zagreb, Croatia.,Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Ingrid Kummer
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Prague, Czech Republic
| | - Margita Držaić
- City Pharmacies Zagreb, Zagreb, Croatia.,Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
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Roux B, Sirois C, Simard M, Gagnon ME, Laroche ML. Reply to Potentially inappropriate medication use in older adults: a reply to Amorim et al. Fam Pract 2021; 38:191-192. [PMID: 32954423 DOI: 10.1093/fampra/cmaa098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, IPPRITT, Faculty of Medicine, University of Limoges, Limoges, France
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Centre of Excellence on Aging of Quebec, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada.,Centre de recherche sur les soins et les services de première ligne de l'Université Laval, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada
| | - Marc Simard
- Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Eve Gagnon
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Office of Information and Studies in Population Health, Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, IPPRITT, Faculty of Medicine, University of Limoges, Limoges, France
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