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Dalton K, Callaghan R, O'Sullivan N, McCarthy L. Community pharmacists' awareness, identification, and management of prescribing cascades: A cross-sectional survey. Res Social Adm Pharm 2024; 20:102-112. [PMID: 38768989 DOI: 10.1016/j.sapharm.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/30/2023] [Accepted: 02/19/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Prescribing cascades can lead to unnecessary medication use, healthcare costs, and patient harm. Pharmacists oversee prescriptions from multiple prescribers and are well positioned to identify such cascades, making pharmacists key stakeholders to address them. OBJECTIVES To evaluate community pharmacists' awareness, identification, and management of prescribing cascades and to assess behavioural determinants that may be targeted in future strategies to minimise inappropriate prescribing cascades. METHODS An online survey was developed using the Theoretical Domains Framework (TDF) and emailed to all registered community pharmacists in Ireland (n = 3775) in November 2021. Quantitative data were analysed using descriptive and inferential statistics. Free-text sections were given to capture reasons for non-resolution of identified prescribing cascades and suggestions to aid prescribing cascade identification and management; this text underwent content analysis. RESULTS Of the 220 respondents, 51% were aware of the term 'prescribing cascade' before the survey, whilst 69% had identified a potentially inappropriate prescribing cascade in practice. Over one third were either slightly confident (26.4%) or not confident at all (10%) in their ability to identify potentially inappropriate prescribing cascades in patients' prescriptions before the survey, whilst 55.2% were concerned that patients were receiving prescribing cascades they had not identified. Most respondents wanted further information/training to help prescribing cascade identification (88.3%) and management (86.1%). Four predominant TDF domains identified were common to both i) influencing non-resolution of identified prescribing cascades and ii) in the suggestions to help identify and manage prescribing cascades: 'Environmental Context and Resources', 'Social/Professional Role and Identity', 'Social Influences' and 'Memory, Attention and Decision Processes'. CONCLUSIONS There is a clear need to provide additional resources to help community pharmacists identify and manage prescribing cascades. These findings will support the development of theory-informed behaviour change strategies to aid the minimisation of inappropriate prescribing cascades and decrease the risk of medication-related harm for patients.
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Affiliation(s)
- Kieran Dalton
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - Robert Callaghan
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - Niamh O'Sullivan
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - Lisa McCarthy
- Leslie Dan Faculty of Pharmacy and Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.
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Singh S, Cocoros NM, Li X, Mazor KM, Antonelli MT, Parlett L, Paullin M, Harkins TP, Zhou Y, Rochon PA, Platt R, Dashevsky I, Massino C, Saphirak C, Crawford SL, Gurwitz JH. Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in the Elderly with Alzheimer's Disease (D-PRESCRIBE-AD): Trial protocol and rationale of an open-label pragmatic, prospective randomized controlled trial. PLoS One 2024; 19:e0297562. [PMID: 38346025 PMCID: PMC10861034 DOI: 10.1371/journal.pone.0297562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 02/15/2024] Open
Abstract
CONTEXT Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia. OBJECTIVES The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics. METHODS The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes. CONCLUSION This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine and Community Health, Division of Health Systems Science, Umass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Noelle M. Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Kathleen M. Mazor
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Mary T. Antonelli
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Lauren Parlett
- Carelon Research, Wilmington, Delaware, United States of America
| | - Mark Paullin
- Carelon Research, Wilmington, Delaware, United States of America
| | - Thomas P. Harkins
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Yunping Zhou
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Paula A. Rochon
- Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Carly Massino
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Cassandra Saphirak
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Sybil L. Crawford
- Division of Health System Science, UMass Chan Medical School, Tan Chingfen Graduate School of Nursing, Worcester, Massachusetts, United States of America
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
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Ndai A, Al Bahou J, Morris E, Wang HM, Marcum Z, Hung A, Brandt N, Steinman MA, Vouri SM. Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system. J Am Geriatr Soc 2024; 72:126-138. [PMID: 38124261 DOI: 10.1111/jgs.18681] [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: 04/24/2023] [Revised: 08/09/2023] [Accepted: 08/28/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. METHODS We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP-Japan, German PRISCUS, European Union-7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High-Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug-induced adverse event) or marker (treatment of drug-induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee-for-service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. RESULTS Out of 480 unique PIMs identified, only three medications-amitriptyline, clomipramine, and imipramine and two drug classes-N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. CONCLUSION We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes.
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Affiliation(s)
- Asinamai Ndai
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Julie Al Bahou
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Earl Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Hsin-Min Wang
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Zach Marcum
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Anna Hung
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Nicole Brandt
- The Peter Lamy Center on Drug Therapy and Aging, University of Maryland, Baltimore, Maryland, USA
| | - Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco and the San Francisco VA Medical Center, San Francisco, California, USA
| | - Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
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Chen Z, Liu Z, Zeng L, Huang L, Zhang L. Research on prescribing cascades: a scoping review. Front Pharmacol 2023; 14:1147921. [PMID: 37465527 PMCID: PMC10350531 DOI: 10.3389/fphar.2023.1147921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
Background: The concept of prescribing cascades has been proposed for more than 20 years, but the research progress and cognitive level varied in different countries. The aim of this study was to systematically evaluate the current status of relevant original research on prescribing cascades, and to provide references for further research and continuous improvement in clinical practice. Methods: We searched three English databases and four Chinese databases from inception until January 2022. Relevant studies about prescribing cascades meeting the eligibility criteria were extracted independently by two reviewers, and a descriptive analysis was conducted to compare the methods and outcomes of the included studies. Results: A total of 32 studies involving 7,075,200 patients in 11 countries were included, including 13 cross-sectional studies, 11 case reports, 7 cohort studies, and 1 case-control study. The target population was mainly elderly people (24 studies). The purpose of the included studies could be divided into three categories: prevention (4 studies), identification (17 studies), and resolution (11 studies) of prescribing cascades. 49 prescribing cascade routes were identified and mainly attributed to the cardiovascular system, most primary diseases of which were dementia, the initial medications of prescribing cascades were mainly calcium channel blockers, and two to six drugs were involved in the prescribing cascade routes. Conclusion: Prescribing cascades have attracted more attention internationally and current studies have mainly focused on the elderly and their cardiovascular diseases and nervous diseases, but still not yet formed integral research in other special populations of drug use, such as children and pregnant women. It is necessary to further conduct in-depth studies with a broader range, and to establish a series of effective measures to decrease the incidence of prescribing cascades in the high-risk group of drug use.
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Affiliation(s)
- Zhe Chen
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Zheng Liu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products in Vitro and in Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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Brown JS, Mendelsohn AB, Nam YH, Maro JC, Cocoros NM, Rodriguez-Watson C, Lockhart CM, Platt R, Ball R, Dal Pan GJ, Toh S. The US Food and Drug Administration Sentinel System: a national resource for a learning health system. J Am Med Inform Assoc 2022; 29:2191-2200. [PMID: 36094070 PMCID: PMC9667154 DOI: 10.1093/jamia/ocac153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/18/2022] [Accepted: 08/18/2022] [Indexed: 07/23/2023] Open
Abstract
The US Food and Drug Administration (FDA) created the Sentinel System in response to a requirement in the FDA Amendments Act of 2007 that the agency establish a system for monitoring risks associated with drug and biologic products using data from disparate sources. The Sentinel System has completed hundreds of analyses, including many that have directly informed regulatory decisions. The Sentinel System also was designed to support a national infrastructure for a learning health system. Sentinel governance and guiding principles were designed to facilitate Sentinel's role as a national resource. The Sentinel System infrastructure now supports multiple non-FDA projects for stakeholders ranging from regulated industry to other federal agencies, international regulators, and academics. The Sentinel System is a working example of a learning health system that is expanding with the potential to create a global learning health system that can support medical product safety assessments and other research.
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Affiliation(s)
- Jeffrey S Brown
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron B Mendelsohn
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Young Hee Nam
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Carla Rodriguez-Watson
- Reagan-Udall Foundation for the Food and Drug Administration, Washington, District of Columbia, USA
| | - Catherine M Lockhart
- Biologics and Biosimilars Collective Intelligence Consortium, Alexandria, Virginia, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Ball
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gerald J Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sengwee Toh
- Corresponding Author: Sengwee Toh, ScD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215, USA;
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Antonelli MT, Cox JS, Saphirak C, Gurwitz JH, Singh S, Mazor KM. Motivating deprescribing conversations for patients with Alzheimer's disease and related dementias: a descriptive study. Ther Adv Drug Saf 2022; 13:20420986221118143. [PMID: 36052398 PMCID: PMC9425903 DOI: 10.1177/20420986221118143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Older adults with Alzheimer’s disease and related dementias (ADRD) are at increased risk of harm due to prescribing of potentially inappropriate medications. Encouraging patients and caregivers to talk with their providers about potentially inappropriate medications could stimulate deprescribing. Our objective was to explore whether mailing educational materials to patients with ADRD might activate patients or caregivers to initiate a conversation with their provider about potentially inappropriate medications. Methods: We conducted semi-structured interviews with patients with ADRD, caregivers of patients with ADRD, and healthcare providers. All participants were shown educational materials referencing potentially inappropriate medications and suggestions to promote deprescribing. Interviews explored reactions to the materials, the idea of patients and caregivers initiating a conversation about deprescribing, and the deprescribing process. Interview transcripts were analyzed using inductive thematic analysis. Results: We conducted a total of 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient–caregiver dyads, and 13 with providers. Patients and caregivers reported that if a medication might cause harm, it would motivate them to talk to their provider about the medication. Trust in the provider could facilitate or inhibit such conversations; conversations would be more likely if there were prior positive experiences asking questions of the provider. Providers were receptive to patients and caregivers initiating conversations about their medications, as they valued deprescribing as part of their clinical practice and welcome informed patients and caregivers as participants in decision-making about medication. Conclusion: Mailing educational materials about potentially inappropriate medications to community-dwelling patients with ADRD may promote deprescribing conversations. Ongoing pragmatic trials will determine whether such interventions stimulate deprescribing conversations and achieve reductions in prescribing of inappropriate medications. Plain Language Summary Encouraging patients with Alzheimer’s disease to talk with their providers about medications that may cause harm Introduction: Older adults with Alzheimer’s disease and related dementias (ADRD) are sometimes prescribed medications that may cause harm, especially when taken for extended periods of time. Patients and their caregivers may not know about the risks. Doctors know of the risks but may not address them due to competing priorities or other challenges in providing care to these patients with complex needs. Encouraging the patient or their caregiver to talk to their doctor about their medications might help to reduce the use of medications that are not beneficial. This study’s goal was to explore whether sending educational materials to patients with ADRD might encourage patients or caregivers to ask their doctor about their medications. Methods: We interviewed patients with ADRD, caregivers, and doctors. We showed them educational materials that suggested patients and their caregivers talk to their doctor about reducing or stopping medications that may be harmful. We asked for reactions to the materials and to the idea of talking to the doctor about stopping the medication. Results: We conducted 27 interviews: 9 with caregivers only, 2 with patients only, 3 with patient–caregiver dyads, and 12 with doctors. Patients and caregivers said learning that a medication might cause harm would motivate them to talk to their doctor about the medication. Trust in their doctor was important. Some patients and caregivers were comfortable asking questions about medications, while others were reluctant to challenge the doctor. Doctors were open to patients and caregivers asking about medications and felt it was important that patients not take medications that are not needed. Conclusion: Sending educational materials to patients with ADRD and caregivers may encourage them to talk with their doctors about stopping or reducing medications. Studies are needed to learn whether such materials lead to reductions in prescribing of potential harmful medications.
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Affiliation(s)
- Mary T Antonelli
- Tan Chingfen Graduate School of Nursing, University of Massachusetts Chan Medical School, 55 N. Lake Ave., Worcester, MA 01655-0112, USA
| | - John S Cox
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Cassandra Saphirak
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Jerry H Gurwitz
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Sonal Singh
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Kathleen M Mazor
- University of Massachusetts Chan Medical School and Meyers Health Care Institute, a joint endeavor of University of Massachusetts Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
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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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