A Delphi process to address medication appropriateness for older persons with multiple chronic conditions

Fried, Terri R.; Niehoff, Kristina M.; Tjia, Jennifer; Redeker, Nancy S.; Goldstein, Mary K.

doi:10.1186/s12877-016-0240-3

Cited by 17 publications

(21 citation statements)

References 34 publications

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“…Disease‐specific treatment guideline use generated much concern among GPs, who thought that they promoted ongoing prescribing and encouraged polypharmacy . General practitioners noted that guidelines did not take into account treatment decisions in the context of multiple morbidities or provide guidance on the appropriate circumstances in which to discontinue medications . Additionally, GPs felt unsure of the usefulness of guidelines, because they were based on clinical trials that rarely included older adults, especially those with multiple morbidities, and did not take into account outcomes valued by the patient …”

Section: Resultsmentioning

confidence: 99%

Deprescribing medications for older adults in the primary care context: A mixed studies review

Gillespie

Harrison

Mullan

2018

Health Science Reports

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Aims: This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. Methods:A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies.Results: Thirty-eight articles were included, and 7 key categories were identified.The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. towards reducing polypharmacy (including deprescribing), from the perspective of both community-living older adults and GPs. This is important because, as mentioned earlier, deprescribing is most often considered in the context of the treatment of older adults. ConclusionsThe purpose of the current review is to build on Bokhof and JuniusWalker 24 work by investigating the factors that influence deprescribing from the perspective of both GPs and adults aged 65 years or older.Independent, community-living older adults are the focus of this review, as the majority of this group retain autonomy and are capable of being responsible for their own health decisions, 17 hence the importance of considering deprescribing from their perspective. Given the increasing evidence that is now available on this topic, a review that incorporates all study types is warranted. Interventions to promote deprescribing will require change on the part of both prescribers and older adults, so it is important to consider how their views interact to create the context where deprescribing discussions can take place. | METHODSA mixed studies review methodology was used as a guide to explore the factors that influence deprescribing. 27,282.1 | Eligibility criteria | Inclusion criteriaFull text primary research articles were included that were available in English, published between January 2000 and December 2017, and that investigated deprescribing or medication cessation/discontinuation in the primary care context for ...

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Section: Resultsmentioning

confidence: 99%

Deprescribing medications for older adults in the primary care context: A mixed studies review

Gillespie

Harrison

Mullan

2018

Health Science Reports

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“…Polypharmacy was defined as seven or more medications based on the least strict count from a panel of experts consensus via Delphi process. 28 …”

Section: Methodsmentioning

confidence: 99%

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Carnahan

Slaven

Callahan

et al. 2017

Journal of the American Medical Directors Association

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Background Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent post-discharge adverse outcomes are poorly understood. Objective To identify whether early post SNF discharge care reduces likelihood of 30 day hospital readmissions. Design Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set. Participants/Setting Older (age > 65), community dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after a SNF stay (n=1,543). Measurements The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge. Results Out of 8,754 community dwelling, hospitalized older adults, 3,025 (34.6%) were discharged to a SNF, of whom 1,543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission (adjusted hazard ratio (aHR) 0.61, p<0.001) but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR=0.67, p= 0.821). Conclusion For patients discharged from a SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30 day hospital readmissions suggests a potential avenue for intervention.

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“…To achieve feasibility, even medications that would otherwise not be considered inappropriate will need to be discontinued. Although this principle is controversial, it achieved consensus support in a Delphi panel examining recommendations for deprescribing …”

Section: Evaluating the Net Benefit Of The Medication Regimenmentioning

confidence: 99%

Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy

Fried

Mecca

2019

J American Geriatrics Society

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Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of “inappropriate” vs “appropriate” polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.

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A Delphi process to address medication appropriateness for older persons with multiple chronic conditions

Cited by 17 publications

References 34 publications

Deprescribing medications for older adults in the primary care context: A mixed studies review

Deprescribing medications for older adults in the primary care context: A mixed studies review

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy

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