Appropriate Prescribing for older adults with Multimorbidity (Pro-M): protocol for a feasibility study

BACKGROUND

Potentially inappropriate prescribing is common among older adults with multimorbidity due to various reasons, from concurrent application of multiple single-disease clinical guidelines to fragmentation of care. Interventions such as medication review have been implemented worldwide to reduce inappropriate prescribing for older adults. However, the implementability of such interventions are underexplored in the outpatient clinics in Singapore's public hospitals. Hence, the Pro-M study aims to assess the feasibility of implementing a physician-pharmacist collaborative care intervention in geriatric medicine outpatient clinics to facilitate appropriate prescribing for older adults in Singapore.

METHODS

This is a single-arm, non-randomised feasibility study using a pre-post evaluation design. This study consists of two parts: (1) implementation phase of the intervention (6 months) and an (2) evaluation phase (3 months). Eligible patients will be recruited from geriatric medicine outpatient clinics at two public hospitals in Singapore through convenience sampling. The main components of the Pro-M intervention are: (1) pharmacist-facilitated medication reviews with feedback on any medication issues and potential recommendations to physicians, and (2) physicians communicating changes to other relevant prescribers. The evaluation phase will involve surveying and interviewing physicians and pharmacists involved in the implementation of the intervention. A mixed-method approach will be employed for data collection and analysis. The quantitative and qualitative findings will be triangulated and reported using Proctor's implementation outcomes: appropriateness, penetration, acceptability, fidelity, feasibility, and sustainability. A basic cost analysis will be conducted alongside the study.

DISCUSSION

This is a phase 2 study to test the feasibility of implementing an intervention that was co-created with stakeholders during phase 1 development of an intervention to optimise prescribing for older adults with multimorbidity. The implementation will be assessed using Proctor's implementation outcomes to provide insights on the process and the feasibility of implementing medication reviews for older adults with multimorbidity as a routine practice in outpatient clinics. Data collected from this study will inform a subsequent scale-up study.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05756478. Registered on 06 March 2023.

Using multiple approaches to develop a physician-pharmacist collaborative care intervention to facilitate appropriate prescribing for older adults with multimorbidity

BACKGROUND AND OBJECTIVES

This article discusses the development process of an intervention to facilitate appropriate prescribing for older adults with multimorbidity at geriatric medicine outpatient clinics. Both effectiveness and implementability were key aims, which were achieved by a systematic combination of different approaches guided by published guidance.

METHODS

Various frameworks and tools were used to guide the intervention development. They include The Medical Research Council Framework for complex health interventions as the overarching framework, supplemented by the Framework of Actions for Intervention Development and a taxonomy of intervention development approaches.

RESULTS

A combination of theory and evidence-based-, implementation-based and partnership approaches were used to develop the intervention. The Behaviour Change Wheel and Theoretical Domains Framework were used for intervention design. Three scoping reviews and two modified Delphi studies were conducted to build an evidence base on prescribing-related barriers and existing interventions. The findings were synthesised, assessed for implementability, and culminated in a co-creation exercise with physicians and pharmacists. The final intervention aims to facilitate collaboration between physicians and pharmacists and to improve communication and documentation of prescribing decisions.

CONCLUSIONS

Multiple approaches may be required when developing interventions that are effective and implementable. The study team's experiences in using published guidance, integrating different approaches, and co-creating the intervention with healthcare professionals provide a useful case study with lessons and insights for developers of complex interventions. Furthermore, systematic reporting of such research-based efforts would contribute to advancement of intervention development in healthcare and reducing research waste.

The World Health Organization (WHO) Integrated Care for Older People (ICOPE) Framework: A Narrative Review on Its Adoption Worldwide and Lessons Learnt

The World Health Organization (WHO) recently published guidelines on the implementation of a new Integrated Care for Older People (ICOPE) framework in 2017-2019. It is an integrated care framework for the screening, assessment, and management of intrinsic capacity (IC) declines. We aimed to examine where the early adopters of ICOPE are across the world, how these study teams and sites plan to apply the framework or have applied it, and the lessons learnt for future adopters. We systematically searched electronic medical and social sciences databases and grey literature published between 31 October 2017 and 31 March 2022. Records were systematically selected using precise inclusion criteria. There were 18 ICOPE study teams and sites across the 29 selected records. Of the 18 study teams and sites, seven were in the development stage, seven conducted feasibility studies, and four have commenced implementation of interventions that applied the ICOPE framework. Future ICOPE adopters may need to make certain decisions. These include whether to adopt ICOPE in the community setting or other settings, whether to adopt only Step 1 on IC screening or additional ICOPE Steps, whether the ICOPE IC screening tool requires modifications, and whether to use digital health technology. We propose the key factors needed to make these decisions and future research needed.

A social ecological approach to identify the barriers and facilitators to COVID-19 vaccination acceptance: A scoping review

BACKGROUND

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus that has caused substantial impact on population health, healthcare, and social and economic systems around the world. Several vaccines have been developed to control the pandemic with varying effectiveness and safety profiles. One of the biggest obstacles to implementing successful vaccination programmes is vaccine hesitancy stemming from concerns about effectiveness and safety. This review aims to identify the factors influencing COVID-19 vaccine hesitancy and acceptance and to organize the factors using the social ecological framework.

METHODS

We adopted the five-stage methodological framework developed by Arksey and O'Malley to guide this scoping review. Selection criteria was based on the PICo (Population, Phenomenon of interest and Context) framework. Factors associated with acceptance and hesitancy were grouped into the following: intrapersonal, interpersonal, institutional, community, and public policy factors using the social ecological framework.

RESULTS

Fifty-one studies fulfilled this review's inclusion criteria. Most studies were conducted in Europe and North America, followed by Asia and the Middle East. COVID-19 vaccine acceptance and hesitancy rates varied across countries. Some common demographic factors associated with hesitancy were younger age, being female, having lower than college education, and having a lower income level. Most of the barriers and facilitators to acceptance of the COVID-19 vaccines were intrapersonal factors, such as personal characteristics and preferences, concerns with COVID-19 vaccines, history/perception of general vaccination, and knowledge of COVID-19 and health. The remaining interpersonal, institution, community, and public policy factors were grouped into factors identified as barriers and facilitators.

CONCLUSION

Our review identified barriers and facilitators of vaccine acceptance and hesitancy and organised them using the social ecological framework. While some barriers and facilitators such as vaccine safety are universal, differentiated barriers might exist for different target groups, which need to be understood if they are to be addressed to maximize vaccine acceptance.

Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines

OBJECTIVE

Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019.

STUDY SELECTION

General prescribing guidelines tailored to or for adults including older adults with multimorbidity.

DATA EXTRACTION

Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes.

RESULTS

Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified.

CONCLUSIONS

From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.

Intervention elements and behavior change techniques to improve prescribing for older adults with multimorbidity in Singapore: a modified Delphi study

PURPOSE

Potentially inappropriate prescribing among older adults is a rising concern, attributed mainly by polypharmacy and multimorbidity. We aimed to identify key components and strategies for construction of a context-relevant intervention to facilitate appropriate prescribing in outpatient clinics in Singapore.

METHODS

The modified Delphi study was conducted in two rounds with 20 geriatricians from seven public hospitals in Singapore. Round one survey presented 69 statements formulated from a scoping review, while round two presented 23 statements with some modifications based on round one comments. The statements were rated against a 7-point Likert scale on their importance and impact on prescribing for older adults with multimorbidty.

RESULTS

Consensus were achieved for 90% of the statements. Seven intervention elements were identified as being important: medication review, training, medication therapy management, shared decision making, patient interview, medication reconciliation, comprehensive geriatric assessment. In addition, some commonly identified behavior change techniques included goal setting (behavior), goal setting (outcome) and problem solving.

CONCLUSIONS

This study identified important intervention elements and their potential strategies that could be adopted in an intervention to optimize appropriate prescribing for older adults with multimorbidity.

Barriers to appropriate prescribing in older adults with multimorbidity: A modified Delphi study

OBJECTIVES

We aimed to understand the barriers experienced by physicians when prescribing for older adults with multimorbidity in specialist outpatient clinics in Singapore.

METHODS

A modified Delphi study was conducted via email with 20 panel experts in the field of geriatric medicine. Barriers identified from an earlier scoping review were presented as statements to the panel.

RESULTS

Eleven barrier statements reached consensus with high importance according to the Delphi panel. Of these statements, seven (64%) belong to the domain of Environmental context and resources in the Theoretical Domains Framework (TDF), while the remaining barriers belong to the domains of skills, knowledge, intentions, and professional/social role and identity. The barriers are further linked to intervention functions in the Behaviour Change Wheel (BCW).

CONCLUSION

Linking the TDF domains to intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing.

A Rapid Review of the Measurement of Intrinsic Capacity in Older Adults

OBJECTIVES

This study aims to address the knowledge gap and summarise the measurement for intrinsic capacity for the five WHO domains across different populations. It specifically aims to identify measurement tools, methods used for computation of a composite intrinsic capacity index and factors associated with intrinsic capacity among older adults.

METHODS

We performed literature review in Medline, including search terms "aged" or "elderly" and "intrinsic capacity" for articles published from 2000 - 2020 in English. Studies which assessed intrinsic capacity in the five WHO domains were included. Information pertaining to study setting, methods used for measuring the domains of intrinsic capacity, computation methods for composite intrinsic capacity index, and details on tool validation were extracted.

RESULTS

Seven articles fulfilling the inclusion criteria were included in the review. Of these, the majority were conducted in community settings (n=5) and were retrospective studies (n=6). The most commonly used tools for assessing intrinsic capacity were gait speed test and chair stand test (locomotion); handgrip-strength and mini-nutritional assessment (vitality); Mini-Mental State Examination (cognition); Geriatric Depression Scale (GDS) and Center for Epidemiological Studies Depression Scale (CES-D) (psychological), and self-reported vision and health questionnaires (sensory). Among the tools used to operationalise the domains, we found variations and non-concordance, especially in the vitality and psychological domains, which make inter-study comparison difficult. Validated scales were less commonly used for vitality and sensory domains. Biomarkers were used for locomotion, vitality, and sensory domains. Self-reported measures were mostly used in the psychological and sensory domains. Three studies operationalised a global score for intrinsic capacity, whereby scores from the individual domains were used to create a composite intrinsic capacity index, using two approaches: a) Structural equation modelling, and b) Sub-scores for each domain which were combined either by arithmetic sum or average.

CONCLUSION

We identified considerable variations in measurement instruments and processes which are used to assess intrinsic capacity, especially among the vitality and psychological domains. A standardized intrinsic capacity composite score for clinical or community settings has not been operationalised yet. Further validation via prospective studies of the intrinsic capacity concept and computation of composite score using validated scales are needed.

Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review

BACKGROUND

As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting.

METHODS

A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data.

RESULTS

A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour.

CONCLUSION

The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Intervention elements to reduce inappropriate prescribing for older adults with multimorbidity receiving outpatient care: a scoping review

OBJECTIVE

Polypharmacy occurs in approximately 30% of older adults aged 65 years or more, particularly among those with multimorbidity. With polypharmacy, there is an associated risk of potentially inappropriate prescribing (PIP). The aims of this scoping review were to (1) identify the intervention elements that have been adopted to reduce PIP in the outpatient setting and (2) determine the behaviour change wheel (BCW) intervention functions performed by each of the identified intervention elements.

DESIGN

Scoping review DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science and Cochrane Library databases, grey literature sources, six key geriatrics journals and the reference lists of review papers.

STUDY SELECTION

All studies reporting an intervention or strategy that addressed PIP in the older adult population (age ≥65) with multimorbidity in the outpatient setting and in which the primary prescriber is the physician.

DATA EXTRACTION

Data extracted from the included studies can be broadly categorised into (1) publication details, (2) intervention details and (3) results. This was followed by data synthesis and analysis based on the BCW framework.

RESULTS

Of 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: 'education', 'persuasion', 'training', 'environmental restructuring' and 'enablement'.

CONCLUSION

PIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.

Electronic Patient-Generated Health Data to Facilitate Disease Prevention and Health Promotion: Scoping Review

BACKGROUND

Digital innovations continue to shape health and health care. As technology socially integrates into daily living, the lives of health care consumers are transformed into a key source of health information, commonly referred to as patient-generated health data (PGHD). With chronic disease prevalence signaling the need for a refocus on primary prevention, electronic PGHD might be essential in strengthening proactive and person-centered health care.

OBJECTIVE

This study aimed to review and synthesize the existing literature on the utilization and implications of electronic PGHD for primary disease prevention and health promotion purposes.

METHODS

Guided by a well-accepted methodological framework for scoping studies, we screened MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, EMBASE, and IEEE Digital Library. We hand-searched 5 electronic journals and 4 gray literature sources, additionally conducted Web searches, reviewed relevant Web pages, manually screened reference lists, and consulted authors. Screening was based on predefined eligibility criteria. Data extraction and synthesis were guided by an adapted PGHD-flow framework. Beyond initial quantitative synthesis, we reported narratively, following an iterative thematic approach. Raw data were coded, thematically clustered, and mapped, allowing for the identification of patterns.

RESULTS

Of 183 eligible studies, targeting knowledge and self-awareness, behavior change, healthy environments, and remote monitoring, most literature (125/183, 68.3%) addressed weight reduction, either through physical activity or nutrition, applying a range of electronic tools from socially integrated to full medical devices. Participants generated their data actively (100/183, 54.6%), in combination with passive sensor-based trackers (63/183, 34.4%) or entirely passively (20/183, 10.9%). The proportions of active and passive data generation varied strongly across prevention areas. Most studies (172/183, 93.9%) combined electronic PGHD with reflective, process guiding, motivational and educational elements, highlighting the role of PGHD in multicomponent digital prevention approaches. Most of these interventions (110/183, 60.1%) were fully automatized, underlining broader trends toward low-resource and efficiency-driven care. Only a fraction (47/183, 25.6%) of studies provided indications on the impact of PGHD on prevention-relevant outcomes, suggesting overall positive trends, especially on vitals (eg, blood pressure) and body composition measures (eg, body mass index). In contrast, the impact of PGHD on health equity remained largely unexplored. Finally, our analysis identified a list of barriers and facilitators clustered around data collection and use, technical and design considerations, ethics, user characteristics, and intervention context and content, aiming to guide future PGHD research.

CONCLUSIONS

The large, heterogeneous volume of the PGHD literature underlines the topic's emerging nature. Utilizing electronic PGHD to prevent diseases and promote health is a complex matter owing to mostly being integrated within automatized and multicomponent interventions. This underlines trends toward stronger digitalization and weaker provider involvement. A PGHD use that is sensitive to identified barriers, facilitators, consumer roles, and equity considerations is needed to ensure effectiveness.