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van Hylckama Vlieg MAM, Pot IE, Visser HPJ, Jong MAC, van der Vorst MJDL, van Mastrigt BJ, Kiers JNA, van den Homberg PPPH, Thijs-Visser MF, Oomen-de Hoop E, van der Heide A, van der Kuy PHM, van der Rijt CCD, Geijteman ECT. Appropriate medication use in Dutch terminal care: study protocol of a multicentre stepped-wedge cluster randomized controlled trial (the AMUSE study). BMC Palliat Care 2024; 23:6. [PMID: 38172930 PMCID: PMC10762916 DOI: 10.1186/s12904-023-01334-x] [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: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Polypharmacy is common among patients with a limited life expectancy, even shortly before death. This is partly inevitable, because these patients often have multiple symptoms which need to be alleviated. However, the use of potentially inappropriate medications (PIMs) in these patients is also common. Although patients and relatives are often willing to deprescribe medication, physicians are sometimes reluctant due to the lack of evidence on appropriate medication management for patients in the last phase of life. The aim of the AMUSE study is to investigate whether the use of CDSS-OPTIMED, a software program that gives weekly personalized medication recommendations to attending physicians of patients with a limited life expectancy, improves patients' quality of life. METHODS A multicentre stepped-wedge cluster randomized controlled trial will be conducted among patients with a life expectancy of three months or less. The stepped-wedge cluster design, where the clusters are the different study sites, involves sequential crossover of clusters from control to intervention until all clusters are exposed. In total, seven sites (4 hospitals, 2 general practices and 1 hospice from the Netherlands) will participate in this study. During the control period, patients will receive 'care as usual'. During the intervention period, CDSS-OPTIMED will be activated. CDSS-OPTIMED is a validated software program that analyses the use of medication based on a specific set of clinical rules for patients with a limited life expectancy. The software program will provide the attending physicians with weekly personalized medication recommendations. The primary outcome of this study is patients' quality of life two weeks after baseline assessment as measured by the EORTC QLQ-C15-PAL questionnaire, quality of life question. DISCUSSION This will be the first study investigating the effect of weekly personalized medication recommendations to attending physicians on the quality of life of patients with a limited life expectancy. We hypothesize that the CDSS-OPTIMED intervention could lead to improved quality of life in patients with a life expectancy of three months or less. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (NCT05351281, Registration Date: April 11, 2022).
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Affiliation(s)
| | - I E Pot
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - H P J Visser
- Department of Internal Medicine, Noordwest Ziekenhuis, Alkmaar, The Netherlands
| | - M A C Jong
- Department of Internal Medicine, Noordwest Ziekenhuis, Alkmaar, The Netherlands
| | - M J D L van der Vorst
- Department of Internal Medicine, Center for Supportive and Palliative Care, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - J N A Kiers
- Family Medicine Network, Nijmegen, The Netherlands
| | | | - M F Thijs-Visser
- Department of Medical Oncology, Ikazia Hospital, Rotterdam, The Netherlands
| | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - P H M van der Kuy
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Alwidyan T, McCorry NK, Black C, Coulter R, Forbes J, Parsons C. Prescribing and deprescribing in older people with life-limiting illnesses receiving hospice care at the end of life: A longitudinal, retrospective cohort study. Palliat Med 2024; 38:121-130. [PMID: 38032069 PMCID: PMC10798021 DOI: 10.1177/02692163231209024] [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: 12/01/2023]
Abstract
BACKGROUND Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population. AIMS To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use. DESIGN A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al. SETTING/PARTICIPANTS Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded. RESULTS Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed. CONCLUSIONS In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death.
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Affiliation(s)
- Tahani Alwidyan
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, Jordan
| | - Noleen K McCorry
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Northern Ireland, UK
| | | | | | - June Forbes
- Northern Ireland Hospice, Belfast, Northern Ireland, UK
| | - Carole Parsons
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
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Raju B, Chaudhary RK, L A, Babu A, Sandeep A, Mateti UV. Rationalizing prescription via deprescribing in oncology practice. J Oncol Pharm Pract 2023; 29:2007-2013. [PMID: 37847585 DOI: 10.1177/10781552231207839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE To provide an integrated approach for deprescribing practice in oncology setting. DATA SOURCES The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included. DATA SUMMARY The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing. CONCLUSION Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.
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Affiliation(s)
- Burnis Raju
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Raushan Kumar Chaudhary
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Ananthesh L
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Anjana Babu
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Ail Sandeep
- Department of Radiation Therapy and Oncology, K S Hegde Medical Academy (KSHEMA), Nitte (Deemed to be University), Mangalore, India
| | - Uday Venkat Mateti
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
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Chaput G, Bhanabhai H. Deprescribing: A Prime Opportunity to Optimize Care of Cancer Patients. Curr Oncol 2023; 30:9701-9709. [PMID: 37999124 PMCID: PMC10670366 DOI: 10.3390/curroncol30110704] [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: 08/18/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023] Open
Abstract
Patients with incurable cancers have an increasing number of comorbidities, which can lead to polypharmacy and its associated adverse events (drug-to-drug interaction, prescription of a potentially inappropriate medication, adverse drug event). Deprescribing is a patient-centered process aimed at optimizing patient outcomes by discontinuing medication(s) deemed no longer necessary or potentially inappropriate. Improved patient quality of life, risk reduction of side effects or worse clinical outcomes, and a decrease in healthcare costs are well-documented benefits of deprescribing. Deprescribing and advance care planning both require consideration of patients' values, preferences, and care goals. Here, we provide an overview of comorbidities and associated polypharmacy risks in cancer patients, as well as useful tools and resources for deprescribing in daily practice, and we shed light on how deprescribing can facilitate advance care planning discussions with patients who have advanced cancer or a limited life expectancy.
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Affiliation(s)
- Genevieve Chaput
- Division of Supportive and Palliative Care, McGill University Health Centre, Department of Family Medicine, McGill University, Montreal, QC H4A 3J1, Canada
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McCaffrey N, Cheah SL, Luckett T, Phillips JL, Agar M, Davidson PM, Boyle F, Shaw T, Currow DC, Lovell M. Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial. PLoS One 2023; 18:e0282465. [PMID: 36854021 PMCID: PMC9974128 DOI: 10.1371/journal.pone.0282465] [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: 12/17/2021] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs. METHODS Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model. RESULTS Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01). CONCLUSIONS In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men. TRIAL REGISTRATION ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.
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Affiliation(s)
- Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood Campus, Burwood, VIC, Australia
- * E-mail:
| | - Seong Leang Cheah
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Jane L. Phillips
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove Brisbane, Queensland
| | - Meera Agar
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Patricia M. Davidson
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital North Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Melanie Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Deprescribing in palliative patients with cancer: a concise review of tools and guidelines. Support Care Cancer 2021; 30:2933-2943. [PMID: 34617161 PMCID: PMC8857105 DOI: 10.1007/s00520-021-06605-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022]
Abstract
Purpose Palliative cancer patients can benefit from deprescribing of potentially inappropriate medications (PIMs). Tools and guidelines developed for the geriatric population are mainly available. This systematic review gives an overview of available guidelines and tools to deprescribe for palliative cancer patients. Methods A systematic search was carried out using the databases SCOPUS and PubMed. Studies focused on palliative cancer patients were included. Results The search identified 137 studies of which 15 studies were included in this systematic review. Six of the included tools were developed specifically for cancer patients. One of these tools was externally validated and applied in several studies and settings. Guidelines or tools that were not specifically developed for cancer patients but that were applied on cohorts of palliative cancer patients were also included. Conclusion Tools developed for geriatric patients contain drugs that are not inappropriate when used in the palliative cancer care setting. Tools developed for cancer patients are more suitable and can be applied in combination with stepwise methods to individualize deprescribing per patient. The tools and guidelines described in this systematic review can be used to further implement deprescribing in the clinical routine for palliative cancer patients.
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Murphy M, Bennett K, Ryan S, Hughes CM, Lavan AH, Cadogan CA. A systematic scoping review of interventions to optimise medication prescribing and adherence in older adults with cancer. Res Social Adm Pharm 2021; 18:2392-2402. [PMID: 33903064 DOI: 10.1016/j.sapharm.2021.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Older adults with cancer often require multiple medications (polypharmacy) comprising cancer-specific treatments, supportive care medications (e.g. analgesics), and medications for pre-existing health conditions. Increasing numbers of medications may increase risks of potentially inappropriate prescribing and non-adherence. OBJECTIVE To provide an overview of evaluations of interventions aimed at optimising medication prescribing and/or adherence in older adults with cancer. METHODS A systematic scoping review was undertaken. Four databases (PubMed, EMBASE, CINAHL, PsycINFO) were searched using relevant search terms (e.g. cancer, older adults). Eligible studies evaluated interventions seeking to improve medication prescribing and/or adherence in older adults (≥65 years) with cancer using a comparative evaluation. All outcomes for studies that met inclusion criteria were included in the review. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS Nine studies met inclusion criteria comprising five randomised controlled trials (RCTs) and four before-and-after study designs. Studies were primarily conducted in oncology clinics, ranging from single study sites to 109 oncology clinics. Sample sizes ranged between 33 and 4844 patients. Interventions most commonly involved patient education (n = 6) delivered by pharmacists or nurses. Three studies reported on prescribing-related outcomes and seven studies reported on adherence-related outcomes, using different terminology and assessment methods. Prescribing-related outcomes focused on medication appropriateness (using Beers criteria) and drug-related problems including drug interactions. Adherence-related outcomes included assessments of self-reported medication adherence and calculation of patients' medication possession ratio. CONCLUSIONS This scoping review highlights a lack of robust evaluations of interventions aimed at optimising medication prescribing and adherence in older adults with cancer. Future research should improve rigour during intervention development, evaluation and reporting in order to generate findings that could inform future practice.
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Affiliation(s)
- Melanie Murphy
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kathleen Bennett
- Population Health Sciences Division, Royal College of Surgeons in Ireland, Dublin, Ireland; Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sinéad Ryan
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom
| | - Amanda H Lavan
- Department of Medicine for the Elderly, St James's Hospital, Dublin, Ireland
| | - Cathal A Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
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Bosetti C, Santucci C, Pasina L, Fortino I, Merlino L, Corli O, Nobili A. Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases. Pharmacoepidemiol Drug Saf 2021; 30:1057-1065. [PMID: 33675260 DOI: 10.1002/pds.5223] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE To evaluate the prescription of preventive medications with questionable usefulness in community dwelling elderly adults with cancer or chronic progressive diseases during the last year of life. METHODS Through the utilization of the healthcare databases of the Lombardy region, Italy, we identified two retrospective cohorts of patients aged 65 years or more, who died in 2018 and had a diagnosis of either a solid cancer (N = 19 367) or a chronic progressive disease (N = 27 819). We estimated prescription of eight major classes of preventive drugs 1 year and 1 month before death; continuation or initiation of preventive drug use during the last month of life was also investigated. RESULTS Over the last year of life, in both oncologic and non-oncologic patients, we observed a modest decrease in the prescription of blood glucose-lowering drugs, anti-hypertensives, lipid-modifying agents, and bisphosphonates, and a slight increase in the prescription of vitamins, minerals, antianemic drugs, and antithrombotic agents (among oncologic patients only). One month before death, the prescription of preventive drugs was still common, particularly for anti-hypertensives, antithrombotics, and antianemics, with more than 60% of patients continuing to be prescribed most preventive drugs and an over 10% starting a therapy with an antithrombotic, an antianemic, or a vitamin or mineral supplement. CONCLUSION These findings support the need for an appropriate drug review and improvement in the quality of drug prescription for vulnerable populations at the end-of-life.
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Affiliation(s)
- Cristina Bosetti
- Department of Oncology, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Claudia Santucci
- Department of Oncology, Unit of Cancer Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Luca Pasina
- Department of Neuroscience, Unit of Pharmacotherapy and Prescription Appropriateness, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ida Fortino
- Regional Ministry of Health, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Ministry of Health, Lombardy Region, Milan, Italy
| | - Oscar Corli
- Department of Oncology, Unit of Pain and Palliative Care Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessandro Nobili
- Department of Neuroscience, Laboratory for Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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10
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Li Y, Whelan CM, Husain AF. Deprescribing in the Home Palliative Setting. J Palliat Med 2020; 24:1030-1035. [PMID: 33326319 DOI: 10.1089/jpm.2020.0376] [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: 11/13/2022] Open
Abstract
Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.
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Affiliation(s)
- Yifan Li
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ciara M Whelan
- Temmy Latner Centre for Palliative Care, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Amna F Husain
- Temmy Latner Centre for Palliative Care Lunenfeld Tanenbaum Research Institute, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
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Haider S, Descallar J, Moylan E, Chua W. Polypharmacy and the use of low or limited value medications in advanced cancer. Intern Med J 2020; 51:1891-1896. [PMID: 33305887 DOI: 10.1111/imj.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with advanced malignancy are often on medications for co-morbidities, including those for primary or secondary prevention. The benefit from these medications can be limited and may result in adverse effects, interact with medications used for the malignancy or associated symptoms, increase pill burden and reduce quality of life. AIMS To evaluate the proportion of patients with advanced malignancy that were continued on low or limited value medications and identify the factors associated with this. We also sought to determine how prevalent polypharmacy was within this group of patients and the factors associated with this. METHODS A retrospective chart review was conducted of patients with incurable malignancy admitted under medical oncology at Liverpool Hospital over a 90-day period. Demographic variables, co-morbidities, disease related parameters and medications were reviewed. Criteria were established to identify low or limited value medications. RESULTS Seventy-eight patients were identified between September and December 2018. Thirty-day mortality was 33%. Sixty-five percent of the cohort was on five or more medications and 24% on 10 or more. One low or limited value medication was reported in 36% and 20% were on two or more. Age ≤60 years was associated with a risk of being on at least one unnecessary medication. Patients with fewer co-morbidities and those in their last 3 months of life were significantly less likely to have polypharmacy. Nine percent of the cohort was on three or more antihypertensives and 6% of patients were on three or more oral hypoglycaemics. CONCLUSION Polypharmacy and continued prescribing of low or limited value medications was identified in a high proportion of patients. Further studies are needed to assess the impact of continuing these medications, as well as investigation of patient and physician attitudes towards de-escalation.
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Affiliation(s)
- Sana Haider
- Liverpool Cancer Therapy Centre, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
| | - Joseph Descallar
- Ingham Institute for Applied Medical Research, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
| | - Eugene Moylan
- Liverpool Cancer Therapy Centre, New South Wales, Australia
| | - Wei Chua
- Liverpool Cancer Therapy Centre, New South Wales, Australia.,Ingham Institute for Applied Medical Research, New South Wales, Australia.,UNSW Sydney, Sydney, New South Wales, Australia
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Abstract
The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.
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Affiliation(s)
- Emma Gardner
- Community Nurse Practitioner, Dorset HealthCare NHS, University NHS Foundation Trust Westminster Memorial Hospital, Dorset
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Abstract
The use of multiple medications is common in palliative care, putting patients at risk of adverse events and a high tablet burden. Deprescribing is the process of reviewing and stopping potentially inappropriate medications in order to improve quality of life. Barriers to deprescribing exist meaning many patients will take multiple medications despite being in the final months of life. The OncPal deprescribing guideline is a useful tool to support the process for patients with a limited life expectancy. There is evidence for the safety of stopping certain medications, particularly those aimed at primary prevention. A systematic process of reviewing individual medications and their appropriateness is recommended.
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Affiliation(s)
- Jo Thompson
- Royal Surrey County Hospital / St Luke's Cancer Centre, Guildford, UK
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