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Meid AD, Gonzalez-Gonzalez AI, Dinh TS, Blom J, van den Akker M, Elders P, Thiem U, Küllenberg de Gaudry D, Swart KMA, Rudolf H, Bosch-Lenders D, Trampisch HJ, Meerpohl JJ, Gerlach FM, Flaig B, Kom G, Snell KIE, Perera R, Haefeli WE, Glasziou P, Muth C. Predicting hospital admissions from individual patient data (IPD): an applied example to explore key elements driving external validity. BMJ Open 2021; 11:e045572. [PMID: 34348947 PMCID: PMC8340284 DOI: 10.1136/bmjopen-2020-045572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients. STUDY DESIGN AND SETTING Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV). RESULTS Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions. CONCLUSIONS Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully. TRIAL REGISTRATION NUMBER PROSPERO id: CRD42018088129.
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Affiliation(s)
- Andreas Daniel Meid
- Department of Clinical Pharmacology & Pharmacoepidemiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Ana Isabel Gonzalez-Gonzalez
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Truc Sophia Dinh
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- School of CAPHRI, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Petra Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amstedarm Public Health Research Institute, Amsterdam, The Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, Hamburg, Germany
| | - Daniela Küllenberg de Gaudry
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karin M A Swart
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amstedarm Public Health Research Institute, Amsterdam, The Netherlands
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Donna Bosch-Lenders
- School of CAPHRI, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Hans J Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | | | - Kym I E Snell
- Centre for Prognosis Research, School of Primary Care Research, Community and Social Care, Keele University, Keele, UK
| | - Rafael Perera
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology & Pharmacoepidemiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Christiane Muth
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany
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Bosch-Lenders D, Jansen J, Stoffers HEJH(J, Winkens B, Aretz K, Twellaar M, Schols JMGA, van der Kuy PHM, Knottnerus JA, van den Akker M. The Effect of a Comprehensive, Interdisciplinary Medication Review on Quality of Life and Medication Use in Community Dwelling Older People with Polypharmacy. J Clin Med 2021; 10:jcm10040600. [PMID: 33562702 PMCID: PMC7915595 DOI: 10.3390/jcm10040600] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/22/2023] Open
Abstract
Background: We conducted a comprehensive medication review at the patients’ home, using data from electronic patient records, and with input from relevant specialists, general practitioners and pharmacists formulated and implemented recommendations to optimize medication use in patients aged 60+ years with polypharmacy. We evaluated the effect of this medication review on quality of life (QoL) and medication use. Methods: Cluster randomized controlled trial (stepped wedge), randomly assigning general practices to one of three consecutive steps. Patients received usual care until the intervention was implemented. Primary outcome was QoL (SF-36 and EQ-5D); secondary outcomes were medication changes, medication adherence and (instrumental) activities of daily living (ADL, iADL) which were measured at baseline, and around 6- and 12-months post intervention. Results: Twenty-four general practices included 360 women and 410 men with an average age of 75 years (SD 7.5). A positive effect on SF-36 mental health (estimated mean was stable in the intervention, but decreased in the control condition with −6.1, p = 0.009,) was found with a reduced number of medications at follow-up compared to the control condition. No significant effects were found on other QoL subscales, ADL, iADL or medication adherence. Conclusion: The medication review prevented decrease of mental health (SF36), with no significant effects on other outcome measures, apart from a reduction in the number of prescribed medications.
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Affiliation(s)
- Donna Bosch-Lenders
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
| | - Jesse Jansen
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
| | - Henri E. J. H. (Jelle) Stoffers
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands;
| | - Karin Aretz
- MEMIC, Center for Data and Information Management, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands;
| | - Mascha Twellaar
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
| | - Jos M. G. A. Schols
- Department of Health Services Research, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands;
| | - Paul-Hugo M. van der Kuy
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands;
| | - J. André Knottnerus
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
| | - Marjan van den Akker
- Department of Family Medicine, Care and Public Health Research Institute (CAHPRI), Maastricht University, 6200 MD Maastricht, The Netherlands; (D.B.-L.); (J.J.); (H.E.J.H.S.); (M.T.); (J.A.K.)
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany
- Academic Centre of General Practice, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Correspondence: ; Tel.: +49-6301-80454
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González-González AI, Dinh TS, Meid AD, Blom JW, van den Akker M, Elders PJM, Thiem U, Kuellenberg de Gaudry D, Snell KIE, Perera R, Swart KMA, Rudolf H, Bosch-Lenders D, Trampisch HJ, Meerpohl JJ, Flaig B, Kom G, Gerlach FM, Hafaeli WE, Glasziou PP, Muth C. Predicting negative health outcomes in older general practice patients with chronic illness: Rationale and development of the PROPERmed harmonized individual participant data database. Mech Ageing Dev 2021; 194:111436. [PMID: 33460622 DOI: 10.1016/j.mad.2021.111436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of multimorbidity and polypharmacy increases significantly with age and are associated with negative health consequences. However, most current interventions to optimize medication have failed to show significant effects on patient-relevant outcomes. This may be due to ineffectiveness of interventions themselves but may also reflect other factors: insufficient sample sizes, heterogeneity of population. To address this issue, the international PROPERmed collaboration was set up to obtain/synthesize individual participant data (IPD) from five cluster-randomized trials. The trials took place in Germany and The Netherlands and aimed to optimize medication in older general practice patients with chronic illness. PROPERmed is the first database of IPD to be drawn from multiple trials in this patient population and setting. It offers the opportunity to derive prognostic models with increased statistical power for prediction of patient-relevant outcomes resulting from the interplay of multimorbidity and polypharmacy. This may help patients from this heterogeneous group to be stratified according to risk and enable clinicians to identify patients that are likely to benefit most from resource/time-intensive interventions. The aim of this manuscript is to describe the rationale behind PROPERmed collaboration, characteristics of the included studies/participants, development of the harmonized IPD database and challenges faced during this process.
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Affiliation(s)
- Ana I González-González
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.
| | - Truc S Dinh
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300RC, Leiden, the Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands; Academic Centre for General Practice, Department of Public Health and Primary Care, KU, Leuven, Belgium
| | - Petra J M Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, 20246, Hamburg, Germany
| | - Daniela Kuellenberg de Gaudry
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary Care Research, Community and Social Care, Keele University, Staffordshire, ST5 5BG, United Kingdom
| | - Rafael Perera
- Nuffield Department of Primary Care, University of Oxford, Oxford, OX2 6GG, United Kingdom
| | - Karin M A Swart
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Donna Bosch-Lenders
- School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands
| | - Hans-Joachim Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany; Cochrane Germany, Cochrane Germany Foundation, Breisacher Strasse 153, 79110, Freiburg, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ghainsom Kom
- Techniker Krankenkasse (TK), 22765, Hamburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Walter E Hafaeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Paul P Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, 4226, Australia
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, 33615, Bielefeld, Germany
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Bosch-Lenders D, Maessen DWHA, Stoffers HEJHJ, Knottnerus JA, Winkens B, van den Akker M. Factors associated with appropriate knowledge of the indications for prescribed drugs among community-dwelling older patients with polypharmacy. Age Ageing 2016; 45:402-8. [PMID: 27013501 DOI: 10.1093/ageing/afw045] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 01/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND polypharmacy contributes to patients' non-adherence with physicians' prescriptions. Patients' knowledge about the indications for their medicines is one of the factors influencing adherence. OBJECTIVE to identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients with polypharmacy. METHODS in a primary care setting, using home interviews and postal questionnaires, patients aged 60 and over who were taking five or more prescribed drugs simultaneously were asked about their medication. Multiple logistic regression analysis was used to evaluate the association (odds ratio, OR) between medication knowledge and explanatory variables like medication use, sex, age, living situation and educational level. RESULTS seven hundred and fifty-four participants (mean age 73.2 years) reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were taking many prescribed drugs (e.g. ≥10 versus ≤5: OR 0.05), age 80 years or over (versus 60-69 years: OR 0.47) and male sex (OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level. CONCLUSION among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 or over, and men. Patients living independently with a partner were more knowledgeable than others.
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Affiliation(s)
- Donna Bosch-Lenders
- School for Public Health and Primary Care (CAHPRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Denny W H A Maessen
- School for Public Health and Primary Care (CAHPRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Henri E J H Jelle Stoffers
- School for Public Health and Primary Care (CAHPRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - J André Knottnerus
- School for Public Health and Primary Care (CAHPRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Bjorn Winkens
- School for Public Health and Primary Care (CAHPRI), Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - Marjan van den Akker
- School for Public Health and Primary Care (CAHPRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands Department of General Practice, KU Leuven, Leuven, Belgium
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Bosch-Lenders D, Maessen DWHA, Stoffers HEJH, Knottnerus JA, Winkens B, van den Akker M. [What do older patients on polypharmacy know about their prescribed drugs?]. Ned Tijdschr Geneeskd 2016; 160:D736. [PMID: 27531251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients on polypharmacy. DESIGN Cross-sectional study. METHOD In a primary care setting, patients aged 60 years and over who were taking five or more prescribed drugs simultaneously were asked about their medication by conducting home interviews and postal questionnaires. Multiple logistic regression analysis was used to evaluate the association between medication knowledge and explanatory variables such as medication use, sex, age, residential status and educational level. RESULTS Seven hundred and fifty-four participants, mean age 73.2 years, reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were: taking many prescribed drugs (≥ 10 vs. ≤ 5 drugs: odds ratio (OR) 0.05), age 80 years or over (vs. 60-69 years: OR 0.47) and male sex (vs. females: OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level. CONCLUSION Among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 years or over, and men. Patients living independently with a partner were more knowledgeable than others.
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Affiliation(s)
- D Bosch-Lenders
- *Dit onderzoek werd eerder gepubliceerd in Age and Ageing (2016;45:402-8) met als titel 'Factors associated with appropriate knowledge of the indications for prescribed drugs among community-dwelling older patients with polypharmacy'. Afgedrukt met toestemming
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Bosch-Lenders D, van den Akker M, Stoffers HEJH, van der Kuy H, Schols JMGA, Knottnerus JA. [How much do patients and health professionals (really) know? The surplus value of a home visit to the patient with polypharmacy by the practice nurse, to support medication reviews in primary care]. Tijdschr Gerontol Geriatr 2013; 44:72-80. [PMID: 23508790 DOI: 10.1007/s12439-013-0015-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse. RESEARCH QUESTIONS What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist? METHOD Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use. RESULTS Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%. CONCLUSIONS Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.
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Affiliation(s)
- D Bosch-Lenders
- Huisarts-onderzoeker, Vakgroep huisartsgeneeskunde UM Maastricht, Maastricht, The Netherlands.
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