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Matsuoka A, Mizutani T, Kaji Y, Yaguchi-Saito A, Odawara M, Saito J, Fujimori M, Uchitomi Y, Shimazu T. Barriers and facilitators to implementing geriatric assessment in daily oncology practice in Japan: A qualitative study using an implementation framework. J Geriatr Oncol 2023; 14:101625. [PMID: 37708801 DOI: 10.1016/j.jgo.2023.101625] [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: 03/07/2023] [Revised: 06/19/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Various guidelines recommend geriatric assessment (GA) for older adults with cancer, but it is not widely implemented in daily practice. This study uses an implementation framework to comprehensively and systematically identify multi-level barriers and facilitators to implementing GA in daily oncology practice. MATERIALS AND METHODS We conducted 16 semi-structured interviews with healthcare providers in 10 designated cancer hospitals in Japan, using purposive and convenience sampling. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of interview data following a deductive content analysis approach with consensual qualitative research methods. After coding the interview data, ratings were assigned to each CFIR construct for each case, reflecting the valence and strength of each construct relative to implementation success. Then, those constructs that appeared to distinguish between high-implementation hospitals (HI) where GA is routinely performed in daily practice and low-implementation hospitals (LI) where GA is performed only for research purposes or not at all were explored. RESULTS Of the 24 CFIR constructs assessed in the interviews, 15 strongly distinguished between HI and LI. In HI, GA was self-administered (Adaptability), or administered via a mobile app with interpretation (Design Quality and Packaging). In HI, healthcare providers were strongly aware of the urgent need to change practice for older adults (Tension for Change) and recognized that GA was compatible with existing workflow as part of their jobs (Compatibility), whereas in LI, they did not realize the need to change practice, and dismissed GA as an extra burden on their heavy workload. In HI, usefulness of GA was widely recognized by healthcare providers (Knowledge & Beliefs about the Intervention), GA had a high priority (Relative Priority) and had strong support from hospital directors, managers, and nursing chiefs (Leadership Engagement), and multiple stakeholders were successfully engaged, including nurses (Key Stakeholders), peer doctors (Opinion Leaders), and those who drive implementation of GA (Champions). DISCUSSION These findings suggest that successful implementation of GA should focus on not only individual beliefs about the usefulness of GA and the complexity of GA itself, but also organizational factors related to hospitals and the engagement of multiple stakeholders.
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Affiliation(s)
- Ayumu Matsuoka
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Tomonori Mizutani
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yuki Kaji
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Akiko Yaguchi-Saito
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan; Faculty of Human Sciences, Tokiwa University, Ibaraki, Japan
| | - Miyuki Odawara
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Junko Saito
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Maiko Fujimori
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Yosuke Uchitomi
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, Institute for Cancer Control, National Cancer Center, Tokyo, Japan.
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Gray SL, Fornaro R, Turner J, Boudreau DM, Wellman R, Tannenbaum C, Marcum ZA, Balderson B, Cook A, Jacobsen AL, Phelan EA. Provider knowledge, beliefs, and self‐efficacy to deprescribe opioids and sedative‐hypnotics. J Am Geriatr Soc 2022; 71:1580-1586. [PMID: 36546768 DOI: 10.1111/jgs.18202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics. METHODS An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses. RESULTS Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively. CONCLUSION Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.
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Affiliation(s)
- Shelly L. Gray
- Department of Pharmacy, School of Pharmacy University of Washington Seattle Washington USA
| | - Rachyl Fornaro
- Department of Pharmacy UW Medicine Valley Medical Center Renton Washington USA
| | - Justin Turner
- Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec Faculté de pharmacie Université de Montréal Montréal Canada
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences Monash University Melbourne Australia
| | - Denise M. Boudreau
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Seattle Washington USA
| | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Seattle Washington USA
| | - Cara Tannenbaum
- Centre de Recherche, Institut universitaire de gériatrie de Montréal, Montréal, Québec Faculté de pharmacie Université de Montréal Montréal Canada
| | - Zachary A. Marcum
- Department of Pharmacy, School of Pharmacy University of Washington Seattle Washington USA
| | - Benjamin Balderson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Seattle Washington USA
| | - Andrea Cook
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Seattle Washington USA
| | | | - Elizabeth A. Phelan
- Department of Medicine, Division of Gerontology and Geriatric Medicine, School of Medicine, and Department of Health Systems and Population Health, School of Public Health University of Washington Seattle Washington USA
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Vicens C, Leiva A, Bejarano F, Sempere-Verdú E, Rodríguez-Rincón RM, Fiol F, Mengual M, Ajenjo-Navarro A, Do Pazo F, Mateu C, Folch S, Alegret S, Coll JM, Martín-Rabadán M, Socias I. Evaluation of a multicomponent intervention consisting of education and feedback to reduce benzodiazepine prescriptions by general practitioners: The BENZORED hybrid type 1 cluster randomized controlled trial. PLoS Med 2022; 19:e1003983. [PMID: 35522626 PMCID: PMC9075619 DOI: 10.1371/journal.pmed.1003983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Current benzodiazepine (BZD) prescription guidelines recommend short-term use to minimize the risk of dependence, cognitive impairment, and falls and fractures. However, many clinicians overprescribe BZDs and chronic use by patients is common. There is limited evidence on the effectiveness of interventions delivered by general practitioners (GPs) on reducing prescriptions and long-term use of BZDs. We aimed to evaluate the effectiveness of a multicomponent intervention for GPs that seeks to reduce BZD prescriptions and the prevalence of long-term users. METHODS AND FINDINGS We conducted a multicenter two-arm, cluster randomized controlled trial in 3 health districts in Spain (primary health centers [PHCs] in Balearic Islands, Catalonia, and Valencian Community) from September 2016 to May 2018. The 81 PHCs were randomly allocated to the intervention group (n = 41; 372 GPs) or the control group (n = 40; 377 GPs). GPs were not blinded to the allocation; however, pharmacists, researchers, and trial statisticians were blinded to the allocation arm. The intervention consisted of a workshop about the appropriate prescribing of BZDs and tapering-off long-term BZD use using a tailored stepped dose reduction with monthly BZD prescription feedback and access to a support web page. The primary outcome, based on 700 GPs (351 in the control group and 349 in the intervention group), compared changes in BZD prescriptions in defined daily doses (DDDs) per 1,000 inhabitants per day after 12 months. The 2 secondary outcomes were the proportion of long-term users (≥6 months) and the proportion of long-term users over age 65 years. Intention-to-treat (ITT) analysis was used to assess all clinical outcomes. Forty-nine GPs (21 intervention group and 28 control group) were lost to follow-up. However, all GPs were included in the ITT analysis. After 12 months, there were a statistically significant decline in total BZD prescription in the intervention group compared to the control group (mean difference: -3.24 DDDs per 1,000 inhabitants per day, 95% confidence interval (CI): -4.96, -1.53, p < 0.001). The intervention group also had a smaller number of long-term users. The adjusted absolute difference overall was -0.36 (95% CI: -0.55, -0.16, p > 0.001), and the adjusted absolute difference in long-term users over age 65 years was -0.87 (95% CI: -1.44, -0.30, p = 0.003). A key limitation of this clustered design clinical trial is the imbalance of some baseline characteristics. The control groups have a higher rate of baseline BZD prescription, and more GPs in the intervention group were women, GPs with a doctorate degree, and trainers of GP residents. CONCLUSIONS A multicomponent intervention that targeted GPs and included educational meeting, feedback about BZD prescriptions, and a support web page led to a statistically significant reduction of BZD prescriptions and fewer long-term users. Although the effect size was small, the high prevalence of BZD use in the general population suggests that large-scale implementation of this intervention could have positive effects on the health of many patients. TRIAL REGISTRATION ISRCTN ISRCTN28272199.
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Affiliation(s)
- Caterina Vicens
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
| | - Alfonso Leiva
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Reseach Unit Primary care Mallorca, Palma, Illes Balears, Spain
- * E-mail:
| | - Ferran Bejarano
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Ermengol Sempere-Verdú
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Raquel María Rodríguez-Rincón
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Francisca Fiol
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Marta Mengual
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Asunción Ajenjo-Navarro
- Conselleria de Sanitat Universal i Salut Pública, Paterna Healthcare Centre, Valencia, Comunitat Valenciana, Spain
| | - Fernando Do Pazo
- Balearic Health Service IbSalut Hospital Universitari Son Espases, Pharmacy Department,Palma de Mallorca, Illes Balears, Spain
| | - Catalina Mateu
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Silvia Folch
- Catalan Institute of Health Cat-salut, DAP Camp de Tarragona, Tarragona, Catalunya, Spain
| | - Santiago Alegret
- Balearic Health Service IbSalut Son Serra-La Vileta Healthcare Centre, Palma, Illes Balears, Spain
| | - Jose Maria Coll
- Balearic Health Service IbSalut, Menorca Primary Care Management, Maó, Illes Baleares, Spain
| | - María Martín-Rabadán
- Balearic Health Service IbSalut, Can Misses Healthcare Centre Ibiza, Illes Baleares, Spain
| | - Isabel Socias
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS)-Balearic Islands Health Research Institute (IdISBa), Mallorca, Spain
- Balearic Health Service IbSalut, Manacor Healthcare Centre, Manacor, Illes Baleares, Spain
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Seidel K, Quasdorf T, Haberstroh J, Thyrian JR. Adapting a Dementia Care Management Intervention for Regional Implementation: A Theory-Based Participatory Barrier Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5478. [PMID: 35564877 PMCID: PMC9101206 DOI: 10.3390/ijerph19095478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Abstract
Dementia is a leading cause of disability and dependency in older people worldwide. As the number of people affected increases, so does the need for innovative care models. Dementia care management (DCM) is an empirically validated approach for improving the care and quality of life for people with dementia (PwD) and caregivers. The aim of this study is to investigate the influencing factors and critical pathways for the implementation of a regionally adapted DCM standard in the existing primary care structures in the German region of Siegen-Wittgenstein (SW). Utilizing participatory research methods, five local health care experts as co-researchers conducted N = 13 semi-structured interviews with 22 local professionals and one caregiver as peer reviewers. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). Our results show that among the most mentioned influencing factors, three CFIR constructs can be identified as both barriers and facilitators: Patients' needs and resources, Relative advantage, and Cosmopolitanism. The insufficient involvement of relevant stakeholders is the major barrier and the comprehensive consideration of patient needs through dementia care managers is the strongest facilitating factor. The study underlines the vital role of barrier analysis in site-specific DCM implementation.
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Affiliation(s)
- Katja Seidel
- Psychological Ageing Research, Department of Psychology, Faculty V: School of Life Sciences, University of Siegen, Adolf-Reichwein-Str. 2a, 57068 Siegen, Germany;
| | - Tina Quasdorf
- German Center for Neurodegenerative Diseases (DZNE), Site Witten, Stockumer Str. 12, 58453 Witten, Germany;
- Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
| | - Julia Haberstroh
- Psychological Ageing Research, Department of Psychology, Faculty V: School of Life Sciences, University of Siegen, Adolf-Reichwein-Str. 2a, 57068 Siegen, Germany;
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Ellernholzstr. 1/2, 17489 Greifswald, Germany;
- Institute for Community Medicine, University Medicine Greifswald, Ellernholzstr. 1-2, 17489 Greifswald, Germany
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The imidazodiazepine, KRM-II-81: An example of a newly emerging generation of GABAkines for neurological and psychiatric disorders. Pharmacol Biochem Behav 2022; 213:173321. [PMID: 35041859 DOI: 10.1016/j.pbb.2021.173321] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
GABAkines, or positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors, are used for the treatment of anxiety, epilepsy, sleep, and other disorders. The search for improved GABAkines, with reduced safety liabilities (e.g., dependence) or side-effect profiles (e.g., sedation) constituted multiple discovery and development campaigns that involved a multitude of strategies over the past century. Due to the general lack of success in the development of new GABAkines, there had been a decades-long draught in bringing new GABAkines to market. Recently, however, there has been a resurgence of efforts to bring GABAkines to patients, the FDA approval of the neuroactive steroid brexanolone for post-partum depression in 2019 being the first. Other neuroactive steroids are in various stages of clinical development (ganaxolone, zuranolone, LYT-300, Sage-324, PRAX 114, and ETX-155). These GABAkines and non-steroid compounds (GRX-917, a TSPO binding site ligand), darigabat (CVL-865), an α2/3/5-preferring GABAkine, SAN711, an α3-preferring GABAkine, and the α2/3-preferring GABAkine, KRM-II-81, bring new therapeutic promise to this highly utilized medicinal target in neurology and psychiatry. Herein, we also discuss possible conditions that have enabled the transition to a new age of GABAkines. We highlight the pharmacology of KRM-II-81 that has the most preclinical data reported. KRM-II-81 is the lead compound in a new series of orally bioavailable imidazodiazepines entering IND-enabling safety studies. KRM-II-81 has a preclinical profile predicting efficacy against pharmacoresistant epilepsies, traumatic brain injury, and neuropathic pain. KRM-II-81 also produces anxiolytic- and antidepressant-like effects in rodent models. Other key features of the pharmacology of this compound are its low sedation rate, lack of tolerance development, and the ability to prevent the development of seizure sensitization.
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