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Mangin D, Lamarche L, Freeman K, Ali A, Clark R, Shah N, Awan A, Langevin J, Parascandalo J, Dore Brown N, Jurcic-Vrataric J, Colwill K, Dragos S, Borhan S, Risdon C, Siu H, Farrell B, Trimble J. Linking Patients' Goals and Priorities to Recommendations for Medication Changes in a Polypharmacy-Focused Structured Clinical Pathway. J Patient Exp 2023; 10:23743735231174762. [PMID: 37213440 PMCID: PMC10196540 DOI: 10.1177/23743735231174762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Polypharmacy is associated with poorer health outcomes in older adults. It is challenging to minimize the harmful effects of medications while maximizing benefits of single-disease-focused recommendations. Integrating patient input can balance these factors. The objectives are to describe the goals, priorities, and preferences of participants asked about these in a structured process to polypharmacy, and to describe the extent that decision-making within the process mapped onto these, signaling a patient-centered approach. This is a single-group quasi-experimental study, nested within a feasibility randomized controlled trial. Patient goals and priorities were mapped to medication recommendations made during the intervention. Overall, there were 33 participants who reported 55 functional goals and 66 symptom priorities, and 16 participants reported unwanted medications. Overall, 154 recommendations for medication alterations occurred. Of those, 68 (44%) recommendations mapped to the individual's goals and priorities, whereas the rest were based on clinical judgment where no priorities were expressed. Our results signal this process supports a patient-centered approach: allowing conversations around goals and priorities in a structured process to polypharmacy should be integrated into subsequent medication decisions.
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Affiliation(s)
- Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Larkin Lamarche
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karla Freeman
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Abbas Ali
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Clark
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nikki Shah
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amen Awan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Langevin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jenna Parascandalo
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Naomi Dore Brown
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kiska Colwill
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Dragos
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sayem Borhan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Henry Siu
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Farrell
- Department of Family Medicine, Bruyère
Research Institute, Ottawa, Ontario, Canada
| | - Johanna Trimble
- Patient Voices Network, BC Patient Safety and Quality
Council, Vancouver, British Columbia, Canada
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Hashemi S, Brown RT, Kelz RR, Fleisher LA, Silber JH. Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions. J Gen Intern Med 2023; 38:1449-1458. [PMID: 36385407 PMCID: PMC10160274 DOI: 10.1007/s11606-022-07897-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers. OBJECTIVE Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions. DESIGN Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia. MAIN MEASURES Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001). CONCLUSION The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Omar I Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sean Hashemi
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca T Brown
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Geriatrics and Extended Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Rachel R Kelz
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
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Liu CK, Miao S, Giffuni J, Katzel LI, Fielding RA, Seliger SL, Weiner DE. Geriatric Syndromes and Health-Related Quality of Life in Older Adults with Chronic Kidney Disease. KIDNEY360 2023; 4:e457-e465. [PMID: 36790849 PMCID: PMC10278840 DOI: 10.34067/kid.0000000000000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/23/2023] [Indexed: 02/16/2023]
Abstract
Key Points In older adults with CKD, geriatric syndromes are common and are associated with reduced quality of life. Addressing geriatric syndromes could potentially improve quality of life for older adults with CKD. Background Geriatric syndromes, which are multifactorial conditions common in older adults, predict health-related quality of life (HRQOL). Although CKD is associated with lower HRQOL, whether geriatric syndromes contribute to HRQOL in CKD is unknown. Our objective was to compare associations of geriatric syndromes and medical conditions with HRQOL in older adults with CKD. Methods This was a secondary analysis of a parallel-group randomized controlled clinical trial evaluating a 12-month exercise intervention in persons 55 years or older with CKD stage 3b–4. Participants were assessed for baseline geriatric syndromes (cognitive impairment, poor appetite, dizziness, fatigue, and chronic pain) and medical conditions (diabetes, hypertension, coronary artery disease, cancer, or chronic obstructive pulmonary disease). Participants' HRQOL was assessed with the Short Form Health Survey-36 (SF-36), EuroQol 5-Dimensions 5-Level, and the EuroQol Visual Analogue Scale. We examined the cross-sectional and longitudinal associations of geriatric syndromes and medical conditions with HRQOL using multiple linear regression. Results Among 99 participants, the mean age was 68.0 years, 25% were female, and 62% were Black. Participants had a baseline mean of 2.0 geriatric syndromes and 2.1 medical conditions; 49% had ≥ two geriatric syndromes and ≥ two medical conditions concurrently. Sixty-seven (68%) participants underwent 12-month assessments. In models using geriatric syndromes and medical conditions as concurrent exposures, the number of geriatric syndromes was cross-sectionally associated with SF-36 scores for general health (β =−0.385) and role limitations because of physical health (β =−0.374) and physical functioning (β =−0.300, all P <0.05). The number of medical conditions was only associated with SF-36 score for role limitations because of physical health (β =−0.205). Conclusions In older adults with CKD stage 3b–4, geriatric syndromes are common and are associated with lower HRQOL. Addressing geriatric conditions is a potential approach to improve HRQOL for older adults with CKD. Clinical Trial registry name and registration number: NCT01462097 ; Registration Date–October 26, 2011.
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Affiliation(s)
- Christine K. Liu
- Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California
- Nutrition Exercise Physiology and Sarcopenia Team, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Jamie Giffuni
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Leslie I. Katzel
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
- Division of Gerontology, Geriatrics, and Palliative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Roger A. Fielding
- Nutrition Exercise Physiology and Sarcopenia Team, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Stephen L. Seliger
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Abstract
The global volume of surgery is increasing. Adverse outcomes after surgery have resource implications and long-term impact on quality of life and consequently represent a significant and underappreciated public health issue. Standardization of outcome reporting is essential for evidence synthesis, risk stratification, perioperative care planning, and to inform shared decision-making. The association between short- and long-term outcomes, which persists when corrected for base-line risk, has significant implications for patients and providers and warrants further investigation. Candidate mechanisms include sustained inflammation and reduced physician activity, which may, in the future, be mitigated by targeted interventions.
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Affiliation(s)
- David Alexander Harvie
- From the Department of Anaesthesia & Perioperative Care and General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Denny Zelda Hope Levett
- From the Department of Anaesthesia & Perioperative Care and General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Michael Patrick William Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, United Kingdom
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5
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Lee J, Singh N, Gray SL, Makris UE. Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More. ACR Open Rheumatol 2022; 4:1031-1041. [PMID: 36278868 PMCID: PMC9746667 DOI: 10.1002/acr2.11503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 12/15/2022] Open
Abstract
The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.
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Affiliation(s)
- Jiha Lee
- JUniversity of MichiganAnn Arbor
| | | | | | - Una E. Makris
- University of Texas Southwestern Medical Center and VA North Texas Health Care SystemDallas
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Charlson ME, Wells MT. Comorbidity: From a Confounder in Longitudinal Clinical Research to the Main Issue in Population Management. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:145-151. [PMID: 35196663 PMCID: PMC9064932 DOI: 10.1159/000521952] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Mary E. Charlson
- Department of Medicine, Weill Cornell Medicine, New York, New York
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7
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De Maria M, Ferro F, Vellone E, Ausili D, Luciani M, Matarese M. Self-care of patients with multiple chronic conditions and their caregivers during the COVID-19 pandemic: A qualitative descriptive study. J Adv Nurs 2021; 78:1431-1447. [PMID: 34846083 DOI: 10.1111/jan.15115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/21/2021] [Accepted: 11/05/2021] [Indexed: 12/23/2022]
Abstract
AIMS Explore the self-care experiences of patients with multiple chronic conditions (MCCs) and caregivers' contributions to patient self-care during COVID-19 pandemic. DESIGN A descriptive qualitative design was used. The COREQ checklist was used for study reporting. METHODS Individual semi-structured interviews were used to collect data from patients with MCCs and caregivers selected from the dataset of an ongoing longitudinal study. Data analysis was performed through deductive thematic analysis. The middle-range theory of self-care of chronic illness, which entails the three dimensions of self-care maintenance, monitoring and management, was used as a theoretical framework to guide data collection and analysis. RESULTS A total of 16 patients and 25 caregivers were interviewed from May to June 2020. The participants were mainly women, with a mean age for patients of 76.25 years and caregivers of 45.76 years; the caregivers were mainly the patients' children (72%). During the pandemic, some patients reported remaining unchanged in their self-care maintenance, monitoring and management behaviours, others intensified their behaviours, and others decreased them. Caregivers played an important role in protecting patients from the risk of contagion COVID-19 and in ensuring patients' self-care of chronic diseases through direct and indirect interventions. CONCLUSIONS Critical events can modify the self-care experiences of chronically ill patients and caregivers' contributions, leading to maintenance, increase or decrease of self-care and contributions to self-care behaviours. IMPACT Patients with MCCs and their caregivers can react in different ways in their performances of self-care and contribution to patients' self-care behaviours when ordinary daily life is disrupted; therefore, nurses should assess such performances during critical events to identify the individuals at risk of reduced self-care and promote the most suitable healthcare services (e.g. eHealth) to implement individualised interventions.
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Affiliation(s)
- Maddalena De Maria
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Federico Ferro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Davide Ausili
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Michela Luciani
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Maria Matarese
- Research Unit of Nursing Science, Campus Bio-medico University of Rome, Rome, Italy
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Smith SM, Wallace E, Clyne B, Boland F, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review. Syst Rev 2021; 10:271. [PMID: 34666828 PMCID: PMC8527775 DOI: 10.1186/s13643-021-01817-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/16/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Multimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review updated and narrowed the focus of a previous Cochrane review and aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care. METHODS We searched eight databases and two trials registers up to 9 September 2019. Two review authors independently screened potentially eligible titles and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health-related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative. RESULTS We included 16 RCTs with 4753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall, the certainty of the evidence was graded as low due to significant variation in study participants and interventions. CONCLUSIONS There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.
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Affiliation(s)
- Susan M. Smith
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Emma Wallace
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Fiona Boland
- Data Science Centre and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
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Tinetti ME, Costello DM, Naik AD, Davenport C, Hernandez-Bigos K, Van Liew JR, Esterson J, Kiwak E, Dindo L. Outcome Goals and Health Care Preferences of Older Adults With Multiple Chronic Conditions. JAMA Netw Open 2021; 4:e211271. [PMID: 33760091 PMCID: PMC7991967 DOI: 10.1001/jamanetworkopen.2021.1271] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals. OBJECTIVE To describe the outcome goals and health care preferences of this population with MCCs. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020. EXPOSURES Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities. MAIN OUTCOMES AND MEASURES Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome. RESULTS Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%). CONCLUSIONS AND RELEVANCE Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.
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Affiliation(s)
- Mary E. Tinetti
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Darcé M. Costello
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
| | - Claire Davenport
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Julia R. Van Liew
- Department of Behavioral Medicine, Medical Humanities, and Bioethics, Des Moines University, Des Moines, Iowa
| | - Jessica Esterson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Eliza Kiwak
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lilian Dindo
- Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Baylor College of Medicine, Houston, Texas
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Chiarelli MT, Antoniazzi S, Cortesi L, Pasina L, Novella A, Venturini F, Nobili A, Mannucci PM. Pharmacist-driven medication recognition/ reconciliation in older medical patients. Eur J Intern Med 2021; 83:39-44. [PMID: 32773274 DOI: 10.1016/j.ejim.2020.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In older medical patients polypharmacy is often associated with poor prescription appropriateness and harmful drug-drug interactions. An effort that jointly involved hospital pharmacists and clinicians attending multimorbid older patients acutely admitted to medical wards was implemented for medication recognition and reconciliation aided by the use of a computerized support system. METHODS Six internal medicine wards enrolled consecutively 90 acutely admitted multimorbid patients aged 75 years or more taking 5 or more different drugs. Two hospital pharmacists carried out the recognition of medications taken at hospital ward admission, and interacted with the clinicians in a process of drug reconciliation, using also the computerized support system to evaluate drug related problems, prescription inappropriateness or drug-drug interactions. The process was repeated at hospital discharge. RESULTS Among a total number of 911 drugs prescribed to 90 older medical patients at ward admission, the pharmacists identified during their recognition/reconciliation 455 drug-related problems, mainly due to prescription of medications inappropriate for older multimorbid patients and clinically harmful drug-drug interactions. When these drug-related problems were identified by the pharmacist, the attending clinicians accepted and implemented the suggestions for changes for approximately two thirds of the discrepancies, thereby leading to deprescribing the implicated drugs or at least to their closer monitoring. CONCLUSIONS This interventional prospective study based upon the integrated expertise of hospital pharmacists and clinicians confirms that drug-related problems are frequent in multimorbid older patients acutely admitted to hospital medical wards, and demonstrates afresh the feasibility and mutual acceptance of a trajectory of recognition/reconciliation based upon an integrated collaboration between hospital pharmacists and ward clinicians in the process of medication optimization.
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Affiliation(s)
- Maria Teresa Chiarelli
- Hospital Pharmacy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Antoniazzi
- Scientific Direction, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Cortesi
- Laboratorio di Valutazione della Qualita' delle Cure e dei Servizi per l'Anziano, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156 Milan, Italy
| | - Luca Pasina
- Laboratorio di Valutazione della Qualita' delle Cure e dei Servizi per l'Anziano, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156 Milan, Italy
| | - Alessio Novella
- Laboratorio di Valutazione della Qualita' delle Cure e dei Servizi per l'Anziano, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156 Milan, Italy
| | - Francesca Venturini
- Hospital Pharmacy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Nobili
- Laboratorio di Valutazione della Qualita' delle Cure e dei Servizi per l'Anziano, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156 Milan, Italy.
| | - Pier Mannuccio Mannucci
- Scientific Direction, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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11
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Rahman FI, Aziz F, Huque S, Ether SA. Medication understanding and health literacy among patients with multiple chronic conditions: A study conducted in Bangladesh. J Public Health Res 2020; 9:1792. [PMID: 32607317 PMCID: PMC7315107 DOI: 10.4081/jphr.2020.1792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/12/2020] [Indexed: 11/23/2022] Open
Abstract
Objectives: Medication understanding is critical for patients who suffer from multiple chronic conditions in order to reduce medication error and is often associated with poor health outcomes and low adherence. This study aims to identify the gap of medication knowledge among multiple chronic condition patients in Bangladesh, in order to aid physicians and other healthcare providers in improving health literacy. Methods: Individual interviews of a convenience sample of multiple chronic condition patients in Bangladesh were held where they were asked a number of questions for assessing medication related literacy. Results: More than 26% patients failed to cite the brand name of all their prescribed medications while the rate of patients not knowing the generic names was far worse (88.1%). Nearly 1 out of every 4 patients did not know the purpose of all their medications and more than half of the participants (55%) did not know the strengths of their drugs. While knowledge about medication routes and regimen was satisfactory, awareness regarding risk factors of medicine was lowest of all. Only 1 out of every 4 patients had a habit of reading drug information leaflet. Patient's ability to correctly state the purpose of their medication seemed to be positively associated with age (p=0.004) and negatively associated with number of medicines taken (p=0.03). Conclusions: Many patients demonstrated poor health literacy regarding medication. Routine review of medications from physician or health provider can significantly improve their health literacy, leading to better treatment outcome and medication adherence.
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Affiliation(s)
| | - Farina Aziz
- Department of Pharmacy, University of Asia Pacific, Dhaka
| | - Sumaiya Huque
- Department of Pharmacy, University of Asia Pacific, Dhaka
| | - Sadia Afruz Ether
- Department of Pharmacy, Daffodil International University, Dhaka, Bangladesh
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12
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Goyal P, Requijo T, Siceloff B, Shen MJ, Masterson Creber R, Hilmer SN, Kronish IM, Lachs MS, Safford MM. Patient-Reported Barriers and Facilitators to Deprescribing Cardiovascular Medications. Drugs Aging 2020; 37:125-135. [PMID: 31858449 PMCID: PMC7339041 DOI: 10.1007/s40266-019-00729-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medications endorsed by clinical practice guidelines, such as cardiovascular medications, could still have risks that outweigh potential benefits, and could thus warrant deprescribing. OBJECTIVES The objective of this study was to develop a framework of facilitators and barriers specific to deprescribing cardiovascular medications in the setting of uncertain benefit. Given the frequent use of β-blockers in heart failure with preserved ejection fraction, and its uncertain benefits with potential for harm, we used this scenario as an example case for a cardiovascular medication that may be reasonable to deprescribe. METHODS We conducted one-on-one, semi-structured interviews of older adults until we reached thematic saturation. Two coders independently reviewed each interview, and developed codes using deductive thematic analysis based on a prior conceptual framework for deprescribing. Subthemes and themes were finalized with a third coder. RESULTS Ten participants were interviewed. We identified three key previously described patient-reported facilitators to deprescribing: (1) appropriateness of cessation; (2) process of cessation; and (3) dislike of medications; and identified three key previously described patient-reported barriers: (1) appropriateness of cessation; (2) process of cessation; and (3) fear. We found that these facilitators and barriers often co-occurred within the same individual. This observation, coupled with subthemes from our patient interviews, yielded two barriers to deprescribing specific to cardiovascular medications-uncertainty and conflicting attitudes. CONCLUSION We adapted a new framework of patient-reported barriers and facilitators specific to deprescribing cardiovascular medications. In addition to addressing barriers previously described, future deprescribing interventions targeting cardiovascular medications must also address uncertainty and conflicting attitudes.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA. .,Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA.
| | - Tatiana Requijo
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Birgit Siceloff
- Division of Cardiology/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA.,Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA
| | - Megan J Shen
- Division of Geriatrics/Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ruth Masterson Creber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Sarah N Hilmer
- Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, NSW, Australia.,Sydney Medical School and Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Mark S Lachs
- Division of Geriatrics/Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Monika M Safford
- Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA
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13
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O'Brien KK, Brown DA, Corbett C, Flanagan N, Solomon P, Vera JH, Aubry R, Harding R. AIDSImpact special issue - broadening the lens: recommendations from rehabilitation in chronic disease to advance healthy ageing with HIV. AIDS Care 2020; 32:65-73. [PMID: 32208741 DOI: 10.1080/09540121.2020.1739203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
People living with HIV are ageing with a combination of physical, mental and social health challenges, known as disability. Although rehabilitation can address disability, the field is still emerging. Our aim was to identify similar disability experiences across complex chronic conditions and establish recommendations for future rehabilitation research and practice to advance healthy ageing with HIV. We conducted a consultation with 77 stakeholders from the United Kingdom, Canada, and Ireland with expertise in the fields of rehabilitation and HIV, cancer, cardiovascular disease, renal disease, or chronic obstructive pulmonary disease who attended a one-day symposium. We used facilitated discussions to identify how rehabilitation issues in complex chronic disease translate to people ageing with HIV, and prioritised recommendations for future practice and research. Disability issues experienced across HIV and other complex chronic diseases included: (i) frailty, (ii) uncertainty and worrying about the future ageing with complex chronic disease, (iii) mental health, (iv) pain, and (v) stigma. We highlight six recommendations for clinical practice and research to advance healthy ageing with HIV. Opportunities for cross-collaboration exist with other more established areas of chronic disease management and rehabilitation. Recommendations can be used to inform future HIV clinical practice and research in this emerging field.
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Affiliation(s)
- Kelly K O'Brien
- Department of Physical Therapy, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada.,Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Canada
| | - Darren A Brown
- Chelsea and Westminster Hospital NHS Foundation Trust, Therapies Department, London, UK
| | | | - Nick Flanagan
- School of Health and Social Care, Teesside University, Middlesbrough, UK.,South Tyneside NHS Foundation Trust, Medical and Respiratory Physiotherapy, South Shields, UK
| | - Patricia Solomon
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Jaime H Vera
- Royal Sussex County Hospital, Brighton, UK.,Department of Global Health and Infection, Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Rachel Aubry
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Richard Harding
- Cicely Saunders Institute, King's College London, London, UK.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King's College London, London, UK
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14
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Green AR. How Can We Optimize Care and Outcomes for Patients with Mild Cognitive Impairment and Acute Myocardial Infarction? J Gen Intern Med 2020; 35:5-7. [PMID: 31659666 PMCID: PMC6957667 DOI: 10.1007/s11606-019-05484-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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15
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Goyal P, Anderson T, Bernacki GM, Marcum ZA, Orkaby A, Kim D, Zullo A, Krishnaswami A, Weissman A, Steinman MA, Rich MW. Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults. J Am Geriatr Soc 2020; 68:78-86. [PMID: 31509233 PMCID: PMC7061460 DOI: 10.1111/jgs.16157] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVES Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN National cross-sectional survey. SETTING Ambulatory. PARTICIPANTS Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine (New York, NY)
| | - Timothy Anderson
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
| | - Gwen M. Bernacki
- Cardiology Division, University of Washington (Seattle, WA), Cambia Palliative Care Center of Excellence (Seattle, WA)
| | | | - Ariela Orkaby
- New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA; Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
| | - Andrew Zullo
- Departments of Epidemiology and Health Services, Policy, and Practice, Brown University School of Public Health (Providence, RI); Center of Innovation in Long Term Services and Supports, Providence VA Medical Center (Providence, RI)
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center (San Jose, CA); Department of Epidemiology and Biostatistics, University of California (San Francisco, CA)
| | | | - Michael A. Steinman
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
- San Francisco Veterans Affairs Medical Center, (San Francisco, CA)
| | - Michael W. Rich
- Cardiovascular Division, Washington University School of Medicine (St. Louis, MO)
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16
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Improving Care Coordination for Comorbidity and Cancer: A Necessity for Patients With Cancer. Cancer Nurs 2019; 43:86-87. [PMID: 31800530 DOI: 10.1097/ncc.0000000000000780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Tonelli MR, Sullivan MD. Person-centred shared decision making. J Eval Clin Pract 2019; 25:1057-1062. [PMID: 31407417 DOI: 10.1111/jep.13260] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 01/08/2023]
Abstract
While multiple versions of shared decision making (SDM) have been advanced, most share two seemingly essential elements: (a) SDM is primarily focused on treatment choices and (b) the clinician is primarily responsible for providing options while the patient contributes values and preferences. We argue that these two elements render SDM suboptimal for clinical practice. We suggest that SDM is better viewed as collaboration in all aspects of clinical care, with clinicians needing to fully engage with the patient's experience of illness and participation in treatment. SDM can only take place within an ongoing partnership between clinician and patient, both respecting the other as a person, not as part of an isolated encounter. Respect for the patient as a person goes beyond respect for their choice. Non-interference is not the only way, or even the most important way, to respect patient autonomy. Knowing the patient as a person and providing an autonomy-supportive context for care are crucial. That is, the clinician must know the patient well enough to be able to answer the patient's question "What would you do, if you were me?" This approach acknowledges clinicians as persons, requiring them to understand patients as persons. We provide examples of such a model of SDM and assert that this pragmatic method does not require excessive time or effort on the part of clinicians or patients but does require direct and particular knowledge of the patient that is often omitted from clinical decisions.
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Affiliation(s)
- Mark R Tonelli
- Department of Medicine, University of Washington, Seattle, Washington
| | - Mark D Sullivan
- Department of Psychiatry, University of Washington, Seattle, Washington
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18
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Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence. PLoS One 2019; 14:e0219875. [PMID: 31765379 PMCID: PMC6876834 DOI: 10.1371/journal.pone.0219875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/05/2019] [Indexed: 11/19/2022] Open
Abstract
Background Chronic edema (CO) is a progressive, physically disfiguring and currently incurable condition. A multifaceted program has been recommended to manage the swelling. However, there is little evidence investigating patients’ perspectives following the program, particularly for those who have poor adherence and/or are disengaged. Aim To investigate the perceived challenges faced by disengaged participants with lower limb CO by identifying their enablers and barriers to participating in a Physiotherapy CO program. Method An exploratory qualitative approach was used. A purposive sampling strategy was adopted to recruit participants. Those with more than three months swelling and who had low adherence and/or attendance (disengaged) to the CO program were invited to participate. Semi-structured interviews with six participants from a CO clinic in a tertiary hospital were conducted. Data were thematically analyzed and findings in terms of enablers and barriers were subsequently reflected in the light of a theoretical framework. Results All six participants were morbidly obese (BMI 47 ± 4 kg/m2) with multiple chronic comorbidities. Enablers and barriers detected included physical, psychological and social factors that interplay to present multidimensional challenges that influence the participants’ adjustment to managing their CO. For the disengaged participants in this study, their under-managed lower limb CO was a progression towards being housebound and having a gradually increasing level of disability. Conclusion This study has identified the multidimensional challenges faced by low adherent and/or disengaged participants with lower limb CO to participating in a hospital-based CO program. Perceived enablers and barriers included physical, psychological and social factors. These were mapped using a health behavior change theoretical framework. Understanding these challenges has implications for developing a multidisciplinary approach aimed at enhancing patient engagement and participation in the physiotherapy CO program.
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19
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Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ, Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med 2019; 179:1528-1536. [PMID: 31424475 PMCID: PMC6705136 DOI: 10.1001/jamainternmed.2019.3007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. OBJECTIVE To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. EXPOSURES Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. RESULTS The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). CONCLUSIONS AND RELEVANCE Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,now with Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Charlie M Wray
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Michael A Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
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20
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Harle CA, DiIulio J, Downs SM, Danielson EC, Anders S, Cook RL, Hurley RW, Mamlin BW, Militello LG. Decision-Centered Design of Patient Information Visualizations to Support Chronic Pain Care. Appl Clin Inform 2019; 10:719-728. [PMID: 31556075 DOI: 10.1055/s-0039-1696668] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND For complex patients with chronic conditions, electronic health records (EHRs) contain large amounts of relevant historical patient data. To use this information effectively, clinicians may benefit from visual information displays that organize and help them make sense of information on past and current treatments, outcomes, and new treatment options. Unfortunately, few clinical decision support tools are designed to support clinical sensemaking. OBJECTIVE The objective of this study was to describe a decision-centered design process, and resultant interactive patient information displays, to support key clinical decision requirements in chronic noncancer pain care. METHODS To identify key clinical decision requirements, we conducted critical decision method interviews with 10 adult primary care clinicians. Next, to identify key information needs and decision support design seeds, we conducted a half-day multidisciplinary design workshop. Finally, we designed an interactive prototype to support the key clinical decision requirements and information needs uncovered during the previous research activities. RESULTS The resulting Chronic Pain Treatment Tracker prototype summarizes the current treatment plan, past treatment history, potential future treatments, and treatment options to be cautious about. Clinicians can access additional details about each treatment, current or past, through modal views. Additional decision support for potential future treatments and treatments to be cautious about is also provided through modal views. CONCLUSION This study designed the Chronic Pain Treatment Tracker, a novel approach to decision support that presents clinicians with the information they need in a structure that promotes quick uptake, understanding, and action.
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Affiliation(s)
- Christopher A Harle
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, United States
| | - Julie DiIulio
- Applied Decision Science, LLC, Dayton, Ohio, United States
| | - Sarah M Downs
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, United States
| | - Elizabeth C Danielson
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, United States
| | - Shilo Anders
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Robert L Cook
- Department of Epidemiology, University of Florida, Gainesville, Florida, United States
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, North Carolina, United States
| | - Burke W Mamlin
- Regenstrief Institute, Indianapolis, Indiana, United States
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21
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Mas MÀ. Multidisciplinary care to older patients with multiple chronic conditions: A challenge for the health system. Med Clin (Barc) 2019; 153:112-114. [DOI: 10.1016/j.medcli.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 11/29/2022]
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