Linking Patients' Goals and Priorities to Recommendations for Medication Changes in a Polypharmacy-Focused Structured Clinical Pathway.
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ABSTRACT:
SUBMITTER: Mangin D
PROVIDER: S-EPMC10196540 | biostudies-literature | 2023
REPOSITORIES: biostudies-literature
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Linking Patients' Goals and Priorities to Recommendations for Medication Changes in a Polypharmacy-Focused Structured Clinical Pathway.
Mangin Dee D Lamarche Larkin L Freeman Karla K Ali Abbas A Clark Rebecca R Shah Nikki N Awan Amen A Langevin Jessica J Parascandalo Jenna J Dore Brown Naomi N Jurcic-Vrataric Jane J Colwill Kiska K Dragos Steven S Borhan Sayem S Risdon Cathy C Siu Henry H Farrell Barbara B Trimble Johanna J
Journal of patient experience 20230517
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 ...[more]
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Project description:BackgroundClinical medication reviews (CMRs) are increasingly performed in older persons with multimorbidity and polypharmacy to reduce drug-related problems (DRPs). However, there is limited evidence that a CMR can improve clinical outcomes. Little attention has been paid to patients' preferences and needs. The aim of this study was to investigate the effect of a patient-centred CMR, focused on personal goals, on health-related quality of life (HR-QoL), and on number of health problems.Methods and findingsThis study was a randomised controlled trial (RCT) performed in 35 community pharmacies and cooperating general practices in the Netherlands. Community-dwelling older persons (≥70 years) with polypharmacy (≥7 long-term medications) were randomly assigned to usual care or to receive a CMR. Randomisation was performed at the patient level per pharmacy using block randomisation. The primary outcomes were HR-QoL (assessed with EuroQol [EQ]-5D-5L and EQ-Visual Analogue Scale [VAS]) and number of health problems (such as pain or dizziness), after 3 and 6 months. Health problems were measured with a self-developed written questionnaire as the total number of health problems and number of health problems with a moderate to severe impact on daily life. Between April 2016 and February 2017, we recruited 629 participants (54% females, median age 79 years) and randomly assigned them to receive the intervention (n = 315) or usual care (n = 314). Over 6 months, in the intervention group, HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval [CI] 0.94 to 5.8; p = 0.006), and the number of health problems with impact on daily life decreased by 12% (difference at 6 months -0.34; 95% CI -0.62 to -0.044; p = 0.024) as compared with the control group. There was no significant difference between the intervention group and control group for HR-QoL measured with EQ-5D-5L (difference at 6 months = -0.0022; 95% CI -0.024 to 0.020; p = 0.85) or total number of health problems (difference at 6 months = -0.30; 95% CI -0.64 to 0.054; p = 0.099). The main study limitations include the risk of bias due to the lack of blinding and difficulties in demonstrating which part of this complex intervention (for example, goal setting, extra attention to patients, reducing health problems, drug changes) contributed to the effects that we observed.ConclusionsIn this study, we observed that a CMR focused on personal goals improved older patients' lives and wellbeing by increasing quality of life measured with EQ-VAS and decreasing the number of health problems with impact on daily life, although it did not significantly affect quality of life measured with the EQ-5D. Including the patient's personal goals and preferences in a medication review may help to establish these effects on outcomes that are relevant to older patients' lives.Trial registrationNetherlands Trial Register; NTR5713.
| S-EPMC6505828 | biostudies-literature
Project description:BackgroundPolypharmacy is associated with poorer health outcomes in older adults. Other than the associated multimorbidity, factors contributing to this association could include medication adverse effects and interactions, difficulties in managing complicated medication regimes, and reduced medication adherence. It is unknown how reversible these negative associations may be if polypharmacy is reduced. The purpose of this study was to determine the feasibility of implementing an operationalized clinical pathway aimed to reduce polypharmacy in primary care and to pilot measurement tools suitable for assessing change in health outcomes in a larger randomized controlled trial (RCT).MethodsWe randomized consenting patients ≥ 70 years old on ≥ 5 long-term medications into intervention or control groups. We collected baseline demographic information and research outcome measures at baseline and 6 months. We assessed four categories of feasibility outcomes: process, resource, management, and scientific. The intervention group received TAPER (team approach to polypharmacy evaluation and reduction), a clinical pathway for reducing polypharmacy using "pause and monitor" drug holiday approach. TAPER integrates patients' goals, priorities, and preferences with an evidence-based "machine screen" to identify potentially problematic medications and support a tapering and monitoring process, all supported by a web-based system, TaperMD. Patients met with a clinical pharmacist and then with their family physician to finalize a plan for optimization of medications using TaperMD. The control group received usual care and were offered TAPER after follow-up at 6 months.ResultsAll 9 criteria for feasibility were met across the 4 feasibility outcome domains. Of 85 patients screened for eligibility, 39 eligible patients were recruited and randomized; two were excluded post hoc for not meeting the age requirement. Withdrawals (2) and losses to follow-up (3) were small and evenly distributed between arms. Areas for intervention and research process improvement were identified. In general, outcome measures performed well and appeared suitable for assessing change in a larger RCT.ConclusionsResults from this feasibility study indicate that TAPER as a clinical pathway is feasible to implement in a primary care team setting and in an RCT research framework. Outcome trends suggest effectiveness. A large-scale RCT will be conducted to investigate the effectiveness of TAPER on reducing polypharmacy and improving health outcomes.Trial registrationclinicaltrials.gov NCT02562352 , Registered September 29, 2015.
| S-EPMC10193598 | biostudies-literature
Project description:IntroductionThe 2020 Focused Asthma Updates introduced a paradigm shift in the treatment of asthma that includes symptom-based adjustments to outpatient asthma treatment that vary by age and severity. The length and complexity of the updates have made them challenging to adopt.MethodsWe implemented an educational session among pediatric residents to increase their familiarity with, comprehension of, and plans to adopt two evidence-based recommendations introduced in the 2020 Updates for symptom-based therapy. Facilitators led groups of four to six pediatric residents in cased-based discussions during a 30-minute, ambulatory care-based session. One week prior, participants and facilitators received synopses of the 2007 Guidelines for the Diagnosis and Management of Asthma and the 2020 Updates. Facilitators also received a guide and scripts explaining new concepts, providing supporting data, and highlighting learning objectives. Retrospective pre/post surveys assessed participants' familiarity with, comprehension of, and planned adoption of recommendations for intermittent steroids and single maintenance and reliever therapy (SMART) before and after the conference. The surveys also assessed prior exposure to the 2020 Updates and reflections on the educational session.ResultsThere were 26 participants. Ratings of familiarity, comprehension, and adoption plans regarding the recommendations significantly improved (ps < .001, Wilcoxon signed rank test). The case-based approach was well received, and the material was deemed relevant.DiscussionThis educational session significantly increased pediatric residents' familiarity with, comprehension of, and plans to adopt two new evidence-based treatments. Dissemination of this educational session may improve outpatient asthma management.
| S-EPMC10333455 | biostudies-literature
Project description:BackgroundThere is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care.Methods and findingsWe conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged ≥65 years with complex multimorbidity, defined as being prescribed ≥15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work.ConclusionsThe SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level.Trial registrationISRCTN Registry ISRCTN12752680.
| S-EPMC8730438 | biostudies-literature
Project description:AimsTo summarize methods used to account for antihyperglycemic medication changes in randomized controlled trials evaluating the effect of dietary and physical activity interventions on glycemia among adults with diabetes.MethodsUsing studies included in two recently published systematic reviews of randomized controlled trials examining the glycemic effects of dietary and physical activity interventions, we evaluated how each study accounted for antihyperglycemic medication changes. Data were analyzed using summary statistics, stratified by the type of intervention studied, and each was assigned a score from 0 to 6 reflecting the strength of medication controls employed.ResultsWe evaluated 22 physical activity focused and 27 dietary focused articles. Our scoring system yielded a mean concurrent medication adjustment score of 3.9/6 for the physical activity studies and a score of 1.7/6 (p < 0.001) for the dietary studies.ConclusionsWe found that randomized controlled trials included in recent systematic reviews of physical activity and dietary interventions did not robustly account or control for changes in antihyperglycemic medications, with physical activity interventions doing so more robustly than dietary interventions. This is a threat to the validity of study findings, as observed glycemic changes may in fact be attributable to imbalances in concurrent medication adjustments between groups.
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Project description:BackgroundHospitalized older adults have a high prevalence of polypharmacy and medication inaccuracies. Gathering the best possible medication history (BPMH) is necessary to accurately identify each medication for multimorbid older adults. The objective was to describe a multipronged approach to obtaining the BPMH for hospitalized older adults, quantify the medication discrepancies identified through these sources, and explore factors associated with these discrepancies.MethodsCross-sectional analysis of 372 hospitalized older adults (age ≥ 50) transitioning to post-acute care as part of a randomized controlled trial to reduce medication burden. We used four information sources to yield a BPMH. Medication discrepancies at hospital admission were categorized as omissions, additions, and dose discrepancies after comparing alternate sources with the electronic medical record (EMR). Multivariate regression analysis, including patient factors (e.g., age, prehospital medication count, number of pharmacies), was performed to identify factors associated with the total count of medication discrepancies.ResultsNinety percent of participants had at least one medication discrepancy and 46% used more than one pharmacy. The majority of discrepancies were omissions. Among the entire cohort, there was a median of two omitted medications per patient across two alternate sources-pharmacy refill history and bedside interview. Lower age, greater total number of prehospital medications, and admission from assisted living or skilled nursing facility were significantly associated with greater medication discrepancies.ConclusionA multipronged and consistent approach to obtain a BPMH during hospitalization for multimorbid older adults revealed medication discrepancies that should be addressed prior to hospital discharge to support safe prescribing practices.
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Project description:BackgroundThe population of cancer survivors is rapidly growing in the United States. Long-term and late effects of cancer, combined with the ongoing management of other chronic conditions, make survivors particularly vulnerable to polypharmacy and its adverse effects. In the current study, the authors examined patterns of prescription medication use and polypharmacy in a population-based sample of cancer survivors.MethodsUsing data from the Medical Expenditure Panel Survey (MEPS), the authors matched cancer survivors (5216 survivors) with noncancer controls (19,588 controls) by age, sex, and survey year. Polypharmacy was defined as ≥5 unique medications. The authors estimated the percentage of respondents prescribed medications within therapeutic classes and total prescription expenditures.ResultsA higher percentage of cancer survivors were prescribed ≥5 unique medications (64.0%; 95% confidence interval [95% CI], 62.3%-65.8%) compared with noncancer controls (51.5%; 95% CI, 50.4%-52.6%), including drugs with abuse potential. Across all therapeutic classes, a higher percentage of newly (≤1 year since diagnosis) and previously (>1 years since diagnosis) diagnosed survivors were prescribed medications compared with controls, with large differences observed with regard to central nervous system agents (65.8% [95% CI, 62.3%-69.3%] vs 57.4% [95% CI, 55.3%-59.5%] vs 46.0% [95% CI, 45.0%-46.9%]). Specifically, nearly 10% of survivors were prescribed benzodiazepines and/or opioids compared with approximately 5% of controls. Survivors had more than double the prescription expenditures (median of $1633 vs $784 among controls). Findings persisted across age and comorbidity categories.ConclusionsCancer survivors were prescribed a higher number of unique medications, including drugs with abuse potential, thereby increasing their risk of adverse drug events, financial toxicity, poor adherence, and drug-drug interactions. Cancer 2018;124:2850-2857. © 2018 American Cancer Society.
| S-EPMC6147245 | biostudies-literature
Project description:BackgroundRoad traffic crashes (RTCs) and its associated injuries are one of the most important public health problems in the world. In Iran, RTCs rank second in terms of mortality. To address this issue, there is a need for research-based interventions. Prioritizing researches using a variety of approaches and frameworks to determine the most effective interventions is a key nodal point in the RTCs' research policy planning cycle. Thus, this study aims to generate and prioritize research questions in the field of RTCs in Iran.MethodsBy adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 25 prominent Iranian academic leaders having role in setting Iran's long-term road safety goals, a group of research funders, and policymakers. The experts' proposed research questions were independently scored on a set of criteria: feasibility, impact on health, impact on the economy, capacity building, and equity. Following the prioritization of Research Questions (RQs), they were all classified using the 5 Pillar frameworks.ResultsIn total, 145 Research Questions were systematically scored by experts against five criteria. Iran's top 20 road traffic safety priorities were established. The RQs related to "road safety management" and "road and infrastructure" achieved a high frequency.ConclusionsThe top 20 research questions in the area of RTCs in Iran were determined by experts. The majority of these RQs were related to "road safety management". The results of this study may contribute to the optimal use of resources in achieving long-term goals in the prevention and control of road traffic crashes and its related injuries. Considering these RQs as research investment options will improve the current status of Road Traffic Injuries (RTIs) at a national level and further advance toward compliance with international goals. If these research priorities are addressed, and their findings are implemented, we can anticipate a significant reduction in the number of crashes, injuries, and deaths.
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Project description:BACKGROUND:Discussing goals of care and advance care planning is beneficial, yet how to best integrate goals of care communication into clinical care remains unclear. OBJECTIVE:To develop and determine the feasibility of a structured goals of care communication guide for nurses and social workers. DESIGN/SETTING/SUBJECTS:Developmental study with providers in an academic and Veterans Affairs (VA) health system (n?=?42) and subsequent pilot testing with patients with chronic obstructive pulmonary disease or heart failure (n?=?15) and informal caregivers (n?=?4) in a VA health system. During pilot testing, the communication guide was administered, followed by semistructured, open-ended questions about the content and process of communication. Changes to the guide were made iteratively, and subsequent piloting occurred until no additional changes emerged. MEASUREMENTS:Provider and patient feedback to the communication guide. RESULTS:Iterative input resulted in the goals of care communication guide. The guide included questions to elicit patient understanding of and attitudes toward the future of illness, clarify values and goals, identify end-of-life preferences, and agree on a follow-up plan. Revisions to guide content and phrasing continued during development and pilot testing. In pilot testing, patients validated the importance of the topic; none said the goals of care discussion should not be conducted. Patients and informal caregivers liked the final guide length (?30 minutes), felt it flowed well, and was clear. CONCLUSIONS:In this developmental and pilot study, a structured goals of care communication guide was iteratively designed, implemented by nurses and social workers, and was feasible based on administration time and acceptability by patients and providers.
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Project description:Small-scale fisheries account for 90% of global fishers and 40% of the global catch. Effectively managing small-scale fisheries is, therefore, crucial to progressing the United Nations Sustainable Development Goals (SDGs). Co-management and community-based fisheries management are widely considered the most appropriate forms of governance for many small-scale fisheries. We outlined relationships between small-scale fisheries co-management and attainment of the SDGs, including evidence for impacts and gaps in dominant logic. We identified 11 targets across five SDGs to which small-scale fisheries co-management (including community-based fisheries management) can contribute; the theory of change by which these contributions could be achieved; and the strength of evidence for progress toward SDG targets related to various co-management strategies. Our theory of change links the 11 SDG targets by qualifying that progress toward some targets is contingent on others being achieved first. We then reviewed 58 case studies of co-management impacts from the Pacific Islands--a region rich in local marine governance--to evaluate evidence of where, to what degree, and with how much certainty different co-management strategies conferred positive impacts to each SDG target. These strategies included access restrictions, permanent area closures, periodic closures, and gear and species restrictions. Although many studies provide evidence linking multiple co-management strategies to improvements in resource status (SDG 14.4), there was limited evidence of follow-on effects, such as improvements in catch (SDG 2.3, 2.4), livelihoods (SDG 1.2), consumption (SDG 2.1), and nutrition (SDG 2.2). Our findings suggest that leaps of logic and assumptions are prevalent in co-management planning and evaluation. Hence, when evaluating co-management impacts against the SDGs, consideration of ultimate goals is required, otherwise, there is a risk of shortfalls between aspirations and impact.
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