Dataset Information

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins.

ABSTRACT:

Objective

To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota.

Patients and methods

During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary team, nurse education, and implementation of an evidence-based deprescribing resource tool. The resource tool included a communication framework to guide deprescribing conversations and a literature summary supporting deprescribing. The project team recorded the number of patients taking 1 of these medications by intermittently surveying the hospice census. Process and counterbalance measures were tracked with online surveys of hospice nursing staff.

Results

At the start of the project, 22 of 69 patients (32%) were taking aspirin, a multivitamin, or a statin. After introduction of the deprescribing resource tool and the addition of a palliative medicine fellow to the interdisciplinary team, this was reduced to 20 of 83 patients (24%), a 24% decrease. Results appeared to be driven primarily by a reduction in multivitamin use (33% decrease). Self-reported comfort and knowledge about deprescribing improved among the hospice nursing staff, as did satisfaction in their workflow from 5.4 to 6.0 (maximum, 7).

Conclusion

The addition of a dedicated team member to address medication issues and provision of an evidence-based deprescribing resource tool appear to reduce the use of unnecessary and potentially harmful medications in ambulatory hospice patients.

SUBMITTER: Low CE

PROVIDER: S-EPMC8325098 | biostudies-literature | 2021 Aug

REPOSITORIES: biostudies-literature

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Publications

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins.

Low Cari E CE Sanchez Pellecer Daniel E DE Santivasi Wil L WL Thompson Virginia H VH Elwood Theresa T Davidson Ashly J AJ Tlusty Julie A JA Feely Molly A MA Ingram Cory C

Mayo Clinic proceedings. Innovations, quality & outcomes 20210724 4

<h4>Objective</h4>To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota.<h4>Patients and methods</h4>During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary tea ...[more]

PMID: 34355129

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Project description:ImportancePolypharmacy is a major health concern among older adults. While deprescribing may reduce inappropriate medicine use, its effect on clinical end points remains uncertain.ObjectiveTo assess the clinical implications of discontinuing the use of statins while maintaining other drugs in a cohort of older patients receiving polypharmacy.Design, setting, and participantsThis retrospective, population-based cohort study included the 29 047 residents in the Italian Lombardy region aged 65 years or older who were receiving uninterrupted treatment with statins, blood pressure-lowering, antidiabetic, and antiplatelet agents from October 1, 2013, until January 31, 2015, with follow-up through June 30, 2018. Data were collected using the health care utilization database of Lombardy region in Italy. Data analysis was conducted from March to November 2020.ExposuresCohort members were followed up to identify those who discontinued statins. Among this group, those who maintained other therapies during the first 6 months after statin discontinuation were 1:1 propensity score matched with patients who discontinued neither statins nor other drugs.Main outcome and measuresThe pairs of patients discontinuing and maintaining statins were followed up from the initial discontinuation until June 30, 2018, to estimate the hazard ratios (HRs) and 95% CIs for fatal and nonfatal outcomes associated with statin discontinuation.ResultsThe full cohort inclued 29 047 patients exposed to polypharmacy (mean [SD] age, 76.5 [6.5] years; 18 257 [62.9%] men). Of them, 5819 (20.0%) discontinued statins while maintaining other medications, and 4010 (68.9%) of them were matched with a comparator. In the discontinuing group, the mean (SD) age was 76.5 (6.4) years, 2405 (60.0%) were men, and 506 (12.6%) had Multisource Comorbidity Scores of 4 or 5. In the maintaining group, the mean (SD) age was 76.1 (6.3) years, 2474 (61.7%) were men, and 482 (12.0%) had multisource comorbidity scores of 4 or 5. Compared with the maintaining group, patients in the discontinuing group had increased risk of hospital admissions for heart failure (HR, 1.24; 95% CI, 1.07-1.43) and any cardiovascular outcome (HR, 1.14; 95% CI, 1.03-1.26), deaths from any cause (HR, 1.15; 95% CI, 1.02-1.30), and emergency admissions for any cause (HR, 1.12; 95% CI, 1.05-1.19).Conclusions and relevanceIn this study of patients receiving polypharmacy, discontinuing statins while maintaining other drug therapies was associated with an increase in the long-term risk of fatal and nonfatal cardiovascular outcomes.

Project description:BACKGROUND:The risk/benefit ratio of using statins for primary prevention of cardiovascular (CV) events in elderly people has not been established. The main objectives of the present study are to assess the cost-effectiveness of statin cessation and to examine the non-inferiority of statin cessation in terms of mortality in patients aged 75 years and over, treated with statins for primary prevention of CV events. METHODS:The "Statins in the elderly" (SITE) study is an ongoing 3-year follow-up, open-label comparative multi-centre, randomized clinical trial that is being conducted in two parallel groups in outpatient primary care offices. Participants meeting the following criteria are included: people aged 75?years and older being treated with statins as primary prevention for CV events, who provide informed consent. After randomization, patients in the statin-cessation strategy are instructed to withdraw their treatment. In the comparison strategy, patients continue their statin treatment at the usual dosage. The cost-effectiveness of the statin-cessation strategy compared to continuing statins will be estimated through the incremental cost per quality-adjusted life years (QALYs) gained at 36?months, from the perspective of the French healthcare system. Overall mortality will be the primary clinical endpoint. We assumed that the mortality rate at 3?years will be 15%. The sample size was computed to achieve 90% power in showing the non-inferiority of statin cessation, assuming a non-inferiority margin of 5% of the between-group difference in overall mortality. In total, the SITE study will include 2430 individuals. DISCUSSION:There is some debate on the value of statins in people over 75?years old, especially for primary prevention of CV events, due to a lack of evidence of their efficacy in this population, potential compliance-related events, drug-drug interactions and side effects that could impair quality of life. Data from clinical trials guide the initiation of medication therapy for primary or secondary prevention of CV disease but do not define the timing, safety, or risks of discontinuing the agents. The SITE study is one of the first to examine whether treatment cessation is a cost-effective and a safe strategy in people of 75?years and over, formerly treated with statins. TRIAL REGISTRATION:ClinicalTrials.gov: NCT02547883. Registered on 11 September 2015.

Project description:ObjectiveThe anti-thrombogenic effects of statins and aspirin have been reported in various malignancies but have not been well examined in endometrial cancer. This study examined the association between statin and/or aspirin use and venous thromboembolism (VTE) risk in endometrial cancer.MethodsThis is a multi-center retrospective study examining 2527 women with endometrial cancer between 2000 and 2015. Statin and aspirin use at diagnosis was correlated to VTE risk during follow-up on multivariable analysis.ResultsThere were 132 VTE events with a 5-year cumulative incidence rate of 6.1%. There were 392 (15.5%) statin users and 219 (8.7%) aspirin users, respectively. On multivariable analysis, statin use was associated with an approximately 60% decreased risk of VTE when compared to non-users (5-year cumulative rates 2.5% versus 6.7%, adjusted-hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.19-0.92, P = 0.030) whereas aspirin did not demonstrate statistical significance (2.0% versus 6.5%, adjusted-HR 0.54, 95%CI 0.19-1.51, P = 0.24). There was a trend of joint effect between statin and aspirin although it did not demonstrate statistical significance: VTE risks for dual statin/aspirin user (adjusted-HR 0.27, 95%CI 0.04-2.07), statin alone (adjusted-HR 0.40, 95%CI 0.18-0.93), and aspirin alone (adjusted-HR 0.51, 95%CI 0.16-1.64) compared to non-use after adjusting for patient characteristics, tumor factors, treatment types, and survival events (P-interaction = 0.090). When stratified by statin type, simvastatin demonstrated the largest reduction of VTE risk (5-year cumulative rates 1.1% versus 6.7%, adjusted-HR 0.17, 95%CI 0.02-1.30, P = 0.088). Obesity, absence of diabetes mellitus, type II histology, and recurrent disease were the factors associated with decreased VTE risk with statin use (all, P-interaction<0.05).ConclusionOur study suggests that statin use may be associated with decreased risk of VTE in women with endometrial cancer.

Dataset Information

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins.

Objective

Patients and methods

Results

Conclusion

Publications

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins.

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