Rhonda Clifford

The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis

AIMS Deprescribing is a suggested intervention to reverse the potential iatrogenic harms of inappropriate polypharmacy. The review aimed to determine whether or not deprescribing is a safe, effective and feasible intervention to modify mortality and health outcomes in older adults. METHODS Specified databases were searched from inception to February 2015. Two researchers independently screened all retrieved articles for inclusion, assessed study quality and extracted data. Data were pooled using RevMan v5.3. Eligible studies included those where older adults had at least one medication deprescribed. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, psychological and physical health outcomes, quality of life, and medication usage (e.g. successful deprescribing, number of medications prescribed, potentially inappropriate medication use). RESULTS A total of 132 papers met the inclusion criteria, which included 34 143 participants aged 73.8 ± 5.4 years. In nonrandomized studies, deprescribing polypharmacy was shown to significantly decrease mortality (OR 0.32, 95% CI: 0.17-0.60). However, this was not statistically significant in the randomized studies (OR 0.82, 95% CI 0.61-1.11). Subgroup analysis revealed patient-specific interventions to deprescribe demonstrated a significant reduction in mortality (OR 0.62, 95% CI 0.43-0.88). However, generalized educational programmes did not change mortality (OR 1.21, 95% CI 0.86-1.69). CONCLUSIONS Although nonrandomized data suggested that deprescribing reduces mortality, deprescribing was not shown to alter mortality in randomized studies. Mortality was significantly reduced when applying patient-specific interventions to deprescribe in randomized studies.

The feasibility and the effect of deprescribing in older adults on mortality and health: A systematic review

AIMS Deprescribing is a suggested intervention to reverse the potential iatrogenic harms of inappropriate polypharmacy. The review aimed to determine whether or not deprescribing is a safe, effective and feasible intervention to modify mortality and health outcomes in older adults. METHODS Specified databases were searched from inception to February 2015. Two researchers independently screened all retrieved articles for inclusion, assessed study quality and extracted data. Data were pooled using RevMan v5.3. Eligible studies included those where older adults had at least one medication deprescribed. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, psychological and physical health outcomes, quality of life, and medication usage (e.g. successful deprescribing, number of medications prescribed, potentially inappropriate medication use). RESULTS A total of 132 papers met the inclusion criteria, which included 34 143 participants aged 73.8 ± 5.4 years. In nonrandomized studies, deprescribing polypharmacy was shown to significantly decrease mortality (OR 0.32, 95% CI: 0.17-0.60). However, this was not statistically significant in the randomized studies (OR 0.82, 95% CI 0.61-1.11). Subgroup analysis revealed patient-specific interventions to deprescribe demonstrated a significant reduction in mortality (OR 0.62, 95% CI 0.43-0.88). However, generalized educational programmes did not change mortality (OR 1.21, 95% CI 0.86-1.69). CONCLUSIONS Although nonrandomized data suggested that deprescribing reduces mortality, deprescribing was not shown to alter mortality in randomized studies. Mortality was significantly reduced when applying patient-specific interventions to deprescribe in randomized studies.

Measuring the Assessment and Counseling Provided with the Supply of Nonprescription Asthma Reliever Medication: A Simulated Patient Study

Background: Over one quarter of asthma reliever medications are provided without prescription by community pharmacies in Australia. Evidence that community pharmacies provide these medications with sufficient patient assessment and medication counseling to ensure compliance with the governments Quality Use of Medicines principles is currently tacking. Objective: To assess current practice when asthma reliever medication is provided in the community pharmacy setting and to identify factors that correlate with assessment of asthma control. Methods: Researchers posing as patients visited a sample of Perth metropolitan community pharmacies in May 2007. During the visit, the simulated patient enacted a standardized scenario of someone with moderately controlled asthma who wished to purchase a salbutamol (albuterol) inhaler without prescription. Results of the encounter were recorded immediately after the visit. Regression analysis was performed, with medication use frequency (a marker of asthma control) as the dependent variable. Results: One hundred sixty community pharmacies in the Perth metropolitan area were visited in May 2007. Pharmacists and/or pharmacy assistants provided some form of assessment in 84% of the visits. Counseling was provided to the simulated patients in 24% of the visits. Only 4 pharmacy staff members asked whether the simulated patient knew how to use the inhaler. Significant correlation was found between assessment and/or counseling of reliever use frequency and 3 independent variables: visit length (p < 0.001), number of assessment questions asked (p < 0.001), and the simulated patient who conducted the visit (p < 0.02). Conclusions: Both patient assessment and medication counseling were suboptimal compared with recommended practice when nonprescription asthma reliever medication was supplied in the community pharmacy setting. Pharmacy and pharmacist demographic variables do not appear to affect assessment of asthma control. This research indicates the need for substantial improvements in practice in order to provide reliever medication in line with Quality Use of Medication principles of ensuring safe and effective use of medication.

Prevalence and predictors of complementary medicine usage in diabetes : Fremantle diabetes study

Aim: To evaluate the use of complementary medicines (CMs) by diabetic patients, and to investigate whether these CMs could affect diabetes control, related comorbidities and existing therapeutic regimens.

Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review

BackgroundThe clinical role of community pharmacists is expanding, as is the use of clinical guidelines in this setting. However, it is unclear which strategies are successful in implementing clinical guidelines and what outcomes can be achieved. The aim of this systematic review is to synthesise the literature on the implementation of clinical guidelines to community pharmacy. The objectives are to describe the implementation strategies used, describe the resulting outcomes and to assess the effectiveness of the strategies.MethodsA systematic search was performed in six electronic databases (Medline, EMBASE, CINAHL, Web of Science, Informit, Cochrane Library) for relevant articles. Studies were included if they reported on clinical guidelines implementation strategies in the community pharmacy setting. Two researchers completed the full-search strategy, data abstraction and quality assessments, independently. A third researcher acted as a moderator. Quality assessments were completed with three validated tools. A narrative synthesis was performed to analyse results.ResultsA total of 1937 articles were retrieved and the titles and abstracts were screened. Full-text screening was completed for 36 articles resulting in 19 articles (reporting on 22 studies) included for review. Implementation strategies were categorised according to a modified version of the EPOC taxonomy. Educational interventions were the most commonly utilised strategy (n = 20), and computerised decision support systems demonstrated the greatest effect (n = 4). Most studies were multifaceted and used more than one implementation strategy (n = 18). Overall outcomes were moderately positive (n = 17) but focused on process (n = 22) rather than patient (n = 3) or economic outcomes (n = 3). Most studies (n = 20) were rated as being of low methodological quality and having low or very low quality of evidence for outcomes.ConclusionsStudies in this review did not generally have a well thought-out rationale for the choice of implementation strategy. Most utilised educational strategies, but the greatest effect on outcomes was demonstrated using computerised clinical decision support systems. Poor methodology, in the majority of the research, provided insufficient evidence to be conclusive about the best implementation strategies or the benefit of clinical guidelines in this setting. However, the generally positive outcomes across studies and strategies indicate that implementing clinical guidelines to community pharmacy might be beneficial. Improved methodological rigour in future research is required to strengthen the evidence for this hypothesis.Protocol registrationPROSPERO 2012:CRD42012003019.

Provision of Primary Care to Patients with Chronic Cough in the Community Pharmacy Setting

Background: Community pharmacies are at the forefront of primary care providers and have an important role in the referral of patients to a medical practitioner for review when necessary. Chronic cough is a common disorder in the community and requires medical assessment. The proficiency of community pharmacy staff to refer patients with chronic cough is currently unknown. Objective: To assess the ability of community pharmacy staff to recognize and medically refer patients with a chronic nonproductive cough. Methods: Following ethics approval, a simulated patient study of 156 community pharmacies in Perth, Western Australia, was conducted over a 3-month period. Simulated patients presented to the pharmacy requesting treatment for a cough. The simulated patient required a referral based on a designated scenario. Demographic details, assessment questions, and advice provided were recorded by the simulated patient immediately postvisit. A logistic regression analysis was performed, with referral for medical assessment as the dependent variable. Results: Of the 155 community pharmacies included in the analysis, 38% provided appropriate medical referral. Cough suppressants were provided as therapy in 72% of all visits. Predictors of medical referral were assessment of symptom duration, medical history, current medications being taken, frequency of reliever use, and the position of the pharmacy staff member conducting the consultation. A third of community pharmacies provided appropriate primary care by recommending medical referral advice to patients with chronic cough. The majority of pharmacy staff members acquired information from the patient that suggested a need for medical referral, yet did not provide referral advice. Conclusions: Appropriate medical referral is more likely when adequate assessment is undertaken and when a pharmacist is directly involved in the consultation. This highlights the need for pharmacies to ensure that processes are in place for patients to access the pharmacist.

Effectiveness of E-learning in Pharmacy Education

Over the past 2 decades, e-learning has evolved as a new pedagogy within pharmacy education. As learners and teachers increasingly seek e-learning opportunities for an array of educational and individual benefits, it is important to evaluate the effectiveness of these programs. This systematic review of the literature examines the quality of e-learning effectiveness studies in pharmacy, describes effectiveness measures, and synthesizes the evidence for each measure. E-learning in pharmacy education effectively increases knowledge and is a highly acceptable instructional format for pharmacists and pharmacy students. However, there is limited evidence that e-learning effectively improves skills or professional practice. There is also no evidence that e-learning is effective at increasing knowledge long term; thus, long-term follow-up studies are required. Translational research is also needed to evaluate the benefits of e-learning at patient and organizational levels.

Chlamydia screening interventions from community pharmacies: a systematic review

BACKGROUND Chlamydia (Chlamydia trachomatis) is the most commonly notified sexually transmissible infection in Australia. Increasing the number of people aged 16-25 years being tested for chlamydia has become a key objective. The strategy recommends that chlamydia screening sites should be easy to access. Community pharmacies are conveniently located and easily accessible. This review aimed to determine the different types of pharmacy-based chlamydia screening interventions, describe their uptake rates, and understand issues around the acceptability of and barriers to testing. METHODS Seven electronic databases were searched for peer-reviewed articles published up to 30 October 2011 for studies that reported chlamydia screening interventions from community pharmacies, or had qualitative evidence on acceptability or barriers linked with interventions. RESULTS Of the 163 publications identified, 12 met the inclusion criteria. Nine reported chlamydia screening interventions in a pharmacy setting, whereas three focussed on perspectives on chlamydia screening. Pharmacists could offer a chlamydia test to consumers attending the pharmacy for a sexual health-related consultation, or consumers could request a chlamydia test as part of a population-based intervention. Participating consumers said pharmacies were accessible and convenient, and pharmacists were competent when offering a chlamydia test. Pharmacists reported selectively offering tests to women they thought would be most at risk, undermining the principles of opportunistic interventions. CONCLUSION Chlamydia screening from community pharmacies is feasible, and can provide an accessible, convenient venue to get a test. Professional implementation support, alongside resources, education and training programs, and incentives may overcome the issue of pharmacists selectively offering the test.

Deprescribing in frail older people – Do doctors and pharmacists agree?

BACKGROUND Deprescribing may reduce harmful polypharmacy in older people and is an accepted clinical practice; however, data to guide deprescribing decisions are scarce. OBJECTIVES This study aimed to determine if physicians and pharmacists agree on medicines to deprescribe. METHODS Two physicians and two pharmacists independently applied a deprescribing decision-making aid to clinical and medicines data collected during a deprescribing trial of frail older people in four residential aged care facilities. The consensus list of medicines selected for deprescribing by the physicians was compared with the consensus list selected by the pharmacists. Lins concordance correlation coefficient (CCC) was used to assess agreement in the number of medicines, and agreement on each specific medicine was assessed using the level 2 intra-cluster correlation (ICC) for medicine within patient. RESULTS Physicians and pharmacists had substantial agreement on the number of medicines to deprescribe (CCC = 0.70; 95% CI: 0.58, 0.82), with a difference of 1.8 ± 2.0 total targeted medicines. For specific medicines, the agreement was moderate (ICC = 0.45, 95% CI: 0.32, 0.58). When considering only orally administered medicines, physicians and pharmacists had substantial agreement (CCC = 0.73; 95% CI: 0.61, 0.84) in the number of medicines, but only moderate agreement for the specific medicines (ICC = 0.44, 95% CI: 0.30, 0.59). CONCLUSIONS Physicians and pharmacists had substantial agreement in the number of medicines they targeted to deprescribe and to continue, but physicians targeted a greater number of medicines for deprescribing than pharmacists. However, they had only moderate agreement in the specific medicines to deprescribe. This suggests that the deprescribing decision-making aid is a useful tool for health professionals to use when considering medicines to deprescribe.

Deprescribing in older people.

Older people with chronic disease have great potential to benefit from their medications but are also at high risk of harm from their medications. The use of medications is particularly important for symptom control and disease progression in older people. Under-treatment means older people can miss out on the potential benefits of useful medications, while over-treatment (polypharmacy) puts them at increased risk of harm. Deprescribing attempts to balance the potential for benefit and harm by systematically withdrawing inappropriate medications with the goal of managing polypharmacy and improving outcomes. The evidence base for deprescribing in older people is growing. Studies to reduce polypharmacy have used a range of methods. Most evidence for deprescribing relates to the withdrawal of specific medications, and evidence supports attempts to deprescribe potentially inappropriate medicines (such as long-term benzodiazepines). There is also evidence that polypharmacy can be reduced by withdrawing specific medications using individualised interventions. More work is needed to identify the sub-groups of older people who may most benefit from deprescribing and the best approaches to undertaking the deprescribing interventions.