Deprescribing in older patients by early-career general practitioners: Prevalence and associations.
Journal
International journal of clinical practice
ISSN: 1742-1241
Titre abrégé: Int J Clin Pract
Pays: India
ID NLM: 9712381
Informations de publication
Date de publication:
Aug 2021
Aug 2021
Historique:
revised:
09
12
2020
received:
12
02
2020
accepted:
03
05
2021
pubmed:
8
5
2021
medline:
24
7
2021
entrez:
7
5
2021
Statut:
ppublish
Résumé
Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs. A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines. One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration). These findings will have important implications for the education of GPs in deprescribing as a clinical skill.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e14325Subventions
Organisme : Australian Deptartment of Health
Informations de copyright
© 2021 John Wiley & Sons Ltd.
Références
Hilmer SN, Gnjidic D. Prescribing for frail older people. Aust. 2017;40:174-178.
Shi S, Klotz U. Age-related changes in pharmacokinetics. Curr Drug Metab. 2011;12:601-610.
Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5:345-351.
Rawle MJ, Cooper R, Kuh D, Richards M. Associations between polypharmacy and cognitive and physical capability: a British birth cohort study. J Am Geriatr Soc. 2018;24:24.
Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust. 2014;201:390-392.
Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175:827-834.
van Middelaar T, Moll van Charante EP. Deprescribing preventive medication in older patients. Br J Gen Pract. 2018;68:456-457.
Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80:1254-1268.
Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging. 2008;25:1021-1031.
Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Int Med. 2017;38:3-11.
Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014:CD008165.
Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82:583-623.
Thio SL, Nam J, van Driel ML, Dirven T, Blom JW. Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials. Br J Gen Pract. 2018;68:e663-e672.
Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy. Sydney: NHMRC Cognitive Decline Partnership Centre, University of Sydney, in Collaboration with the Australian Deprescribing Network and NPS MedicineWise; 2018.
Magin P, Goode S, Pond D. GPs, medications and older people: a qualitative study of general practitioners' approaches to potentially inappropriate medications in older people. Australas J Ageing. 2015;34:134-139.
Reeve E, Low L-F, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study. Br J Gen Pract. 2016;66:e552-e560.
Kouladjian L, Gnjidic D, Reeve E, Chen TF, Hilmer SN. Health care practitioners' perspectives on deprescribing anticholinergic and sedative medications in older adults. Ann Pharmacother. 2016;50:625-636.
Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in frail older people: a randomised controlled trial. PLoS One. 2016;11:e0149984.
Gulliford M, Ravindrarajah R, Hamada S, Jackson S, Charlton J. Inception and deprescribing of statins in people aged over 80 years: cohort study. Age Ageing. 2017;46:1001-1005.
Allard J, Hebert R, Rioux M, Asselin J, Voyer L. Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. CMAJ. 2001;164:1291-1296.
Gnjidic D, Le Couteur DG, Abernethy DR, Hilmer SN. A pilot randomized clinical trial utilizing the drug burden index to reduce exposure to anticholinergic and sedative medications in older people. Ann Pharmacother. 2010;44:1725-1732.
Weber V, White A, McIlvried R. An electronic medical record (EMR)-based intervention to reduce polypharmacy and falls in an ambulatory rural elderly population. J Gen Intern Med. 2008;23:399-404.
Salonoja M, Salminen M, Vahlberg T, Aarnio P, Kivela SL. Withdrawal of psychotropic drugs decreases the risk of falls requiring treatment. Arch Gerontol Geriatr. 2012;54:160-167.
Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. JAMA. 2018;320:1889-1898.
Australian Government, Department of Health, Health Workforce Division. Method Summaries. GP headcount and workload methods. https://hwd.health.gov.au/resources/information/methods-gp-headcount-and-workload.pdf. Accessed November 13, 2020.
Taylor R, Radloff A, Edwards D, Clarke L. National report on the 2017 National Registrar Survey: Australian General Practice Training Program; 2018.
Morgan S, Magin PJ, Henderson KM, et al. Study protocol: the Registrar Clinical Encounters in Training (ReCEnT) study. BMC Fam Pract. 2012;13:50.
Magin P, Morgan S, Henderson K, et al. The Registrars’ Clinical Encounters in Training (ReCEnT) project: educational and research aspects of documenting GP trainees’ clinical experience. Aust Fam Physician. 2015;44:681-684.
Motter FR, Fritzen JS, Hilmer SN, Paniz EV, Paniz VMV. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol. 2018;74:679-700.
Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med. 2007;167:781-787.
American. Geriatrics Society Expert Panel. Updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246.
Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process. PLoS One. 2015;10:e0122246.
WHO Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) classification system. Structure and principles. http://www.whocc.no/atc/structure_and_principles/. Accessed May 16, 2021.
Australian Institute of Health and Welfare 2015. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. 2015. Cat. no. IHW 147. Canberra: AIHW.
Australian Bureau of Statistics. Australian Standard Geographical Classification (ASGC). 2006. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/1AE106C101420508CA2571A900170741. Accessed February 1, 2019.
Australian Bureau of Statistics. 2039.0 - Information Paper: An Introduction to Socio-economic Indexes of Areas (SEIFA). 2006. http://www.abs.gov.au/ausstats/abs@.nsf/mf/2039.0/. Accessed February 1, 2019.
Britt H. A new coding tool for computerised clinical systems in primary care-ICPC plus. Aust Fam Physician. 1997;26(Suppl 2):S79-S82.
O'Halloran J, Miller GC, Britt H. Defining chronic conditions for primary care with ICPC-2. Fam Pract. 2004;21:381-386.
Morgan SG, Hunt J, Rioux J, Proulx J, Weymann D, Tannenbaum C. Frequency and cost of potentially inappropriate prescribing for older adults: a cross-sectional study. CMAJ Open. 2016;4:E346-E351.
Narayan SW, Nishtala PS. Prevalence of potentially inappropriate medicine use in older New Zealanders: a population-level study using the updated 2012 Beers criteria. J Eval Clin Pract. 2015;21:633-641.
Price SD, Holman CD, Sanfilippo FM, Emery JD. Are older Western Australians exposed to potentially inappropriate medications according to the Beers Criteria? A 13-year prevalence study. Australas J Ageing. 2014;33:E39-48.
Byrne CJ, Walsh C, Cahir C, Ryan C, Williams DJ, Bennett K. Anticholinergic and sedative drug burden in community-dwelling older people: a national database study. BMJ Open. 2018;8:e022500.
Jamieson HA, Nishtala PS, Scrase R, et al. Drug burden index and its association with hip fracture among older adults: a national population-based study. J Gerontol A Biol Sci Med Sci. 2018;31:31.
Jamsen KM, Gnjidic D, Hilmer SN, et al. Drug Burden Index and change in cognition over time in community-dwelling older men: the CHAMP study. Ann Med. 2017;49:157-164.
Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;1:E659-E666.
Al-Yaman F. The Australian burden of disease study: impact and causes of illness and death in aboriginal and Torres strait islander people, 2011. Public health res. 2017;27:11.
Jiron M, Pate V, Hanson LC, Lund JL, Jonsson Funk M, Sturmer T. Trends in prevalence and determinants of potentially inappropriate prescribing in the United States: 2007 to 2012. J Am Geriatr Soc. 2016;64:788-797.
Gnjidic D, Le Couteur DG, Blyth FM, et al. Statin use and clinical outcomes in older men: a prospective population-based study. BMJ Open. 2013;3:9.
Bonney A, Morgan S, Tapley A, et al. Older patients’ consultations with general practice trainees: a cross-sectional study. Australasian Journal on Ageing. 2017;36(1):E1-E7. https://doi.org/10.1111/ajag.12364
Magin P, Morgan S, Henderson K, et al. Family medicine trainees' clinical experience of chronic disease during training: a cross-sectional analysis from the registrars' clinical encounters in training study. BMC Med Educ. 2014;14:260.
Pearlman J, Morgan S, van Driel M, et al. Continuity of care in general practice vocational training: prevalence, associations and implications for training. Education for Primary Care. 2016;27:27-36.
Bonevski B, Magin P, Horton G, Foster M, Girgis A. Response rates in GP surveys - trialling two recruitment strategies. Aust Fam Physician. 2011;40:427-430.