Man vs. machine: comparison of pharmacogenetic expert counselling with a clinical medication support system in a study with 200 genotyped patients

Background Medication problems such as strong side effects or inefficacy occur frequently. At our university hospital, a consultation group of specialists takes care of patients suffering from medication problems. Nevertheless, the counselling of poly-treated patients is complex, as it requires the consideration of a large network of interactions between drugs and their targets, their metabolizing enzymes, and their transporters, etc. Purpose This study aims to check whether a score-based decision-support system (1) reduces the time and effort and (2) suggests solutions at the same quality level. Patients and methods A total of 200 multimorbid, poly-treated patients with medication problems were included. All patients were considered twice: manually, as clinically established, and using the Drug-PIN decision-support system. Besides diagnoses, lab data (kidney, liver), phenotype (age, gender, BMI, habits), and genotype (genetic variants with actionable clinical evidence I or IIa) were considered, to eliminate potentially inappropriate medications and to select individually favourable drugs from existing medication classes. The algorithm is connected to automatically updated knowledge resources to provide reproducible up-to-date decision support. Results The average turnaround time for manual poly-therapy counselling per patient ranges from 3 to 6 working hours, while it can be reduced to ten minutes using Drug-PIN. At the same time, the results of the novel computerized approach coincide with the manual approach at a level of > 90%. The holistic medication score can be used to find favourable drugs within a class of drugs and also to judge the severity of medication problems, to identify critical cases early and automatically. Conclusion With the computerized version of this approach, it became possible to score all combinations of all alternative drugs from each class of drugs administered (“personalized medication landscape “) and to identify critical patients even before problems are reported (“medication alert”). Careful comparison of manual and score-based results shows that the incomplete manual consideration of genetic specialties and pharmacokinetic conflicts is responsible for most of the (minor) deviations between the two approaches. The meaning of the reduction of working time for experts by about 2 orders of magnitude should not be underestimated, as it enables practical application of personalized medicine in clinical routine.

The impact of including a medication review in an integrated care pathway: a pilot study

Objective: Our hypothesis was that the intervention would decrease (or at least not increase) the number of potentially inappropriate medications (PIMs) and the number of hospital readmissions within 30 days of discharge per hospital stay. Methods: A cohort of hospitalized older adults enrolled in the PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. It was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in general hospital, age 75 or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive, and performance of a medication review. Results: For the study population (n=582), the mean ± standard deviation age was 82.9 ± 4.9, and 190 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] upon admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge, relative to patients in the unexposed cohort. Conclusion: Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, the integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.

Continue Or Not To Continue? Attitudes Towards Deprescribing Among Community- Dwelling Older Adults In China

Background: Inappropriate prescribing of medications and polypharmacy among older adults are associated with a wide range of adverse outcomes. It is critical to understand the attitudes towards deprescribing—reducing the use of potentially inappropriate medications (PIMs)—among this vulnerable group. Such information is particularly lacking in low - and middle-income countries.Methods: The present study examined attitudes towards deprescribing and individual-based characteristics that might be associated with these attitudes among community-dwelling older adults in China. We conducted a cross-sectional study through in-person interviews using the Patients' Attitudes Towards Deprescribing (PATD) and the revised PATD (rPATD) (version for older adults) questionnaires in two communities through the community-based physical examination platform in China. Participants were 65 years and older and had at least one chronic disease and one regular prescription medication.Results: Of the 1,897 participants in this study, average age was 73.8 years (SD=6.2 years) and 1,023 (53.9%) were women. The majority had one chronic disease (n=1,364 [71.9%]) and took 1-2 medications (n=1,483 [78.2%]). A total of 947 (50.0%) older adults reported being willing to stop taking one or more of their medicines if their physician said it was possible, and 1,204 (63.5%) older adults wanted to stop a medicine been taking for a long time. We did not find Individual-level factors to be associated with attitudes towards deprescribing. Conclusions: The proportions of participants’ willingness to deprescribing were much lower than what prior investigations among western populations reported. It is important to identify the reasons for the low wiliness to deprescribe and develop a patient-centered and practical deprescribing guideline that is suitable for Chinese older adults.

Prevalence and Factors that Influence Potentially Inappropriate Medication Use among Thai Elderly in Primary Care Settings

Background Older age increases the likelihood of chronic diseases and polypharmacy with the likelihood of potentially inappropriate medications (PIMs) in secondary and tertiary care levels, but in the primary care settings of Thailand there still is a need for more evidence. This study aimed to examine the prevalence of PIM in primary care settings, and to identify factors that influence the use of PIM. Methods A cross-sectional retrospective study was conducted in 2017. Eight primary care units from four regions of Thailand were randomly selected. People aged ≥ 60 years in the eight units were studied as participants. The List of Risk Drugs for Thai Elderly (LRDTE) was used as the reference. Multivariate logistic regression was carried out to identify factors that influence. Results A total of 4,848 patients aged ≥60 years with 20,671 prescriptions were studied. The mean age was 70.7±8.3 years for males, and 61.2% for females. A little more than 5% (5.1%) had ≥ 3 chronic diseases and 15.0% received polypharmacy ( ≥5 medications). The prevalence of prescriptions with PIMs was 65.9%. The most frequent PIMs were antidepressants: amitriptyline (28.1%), antihistamines: dimenhydrinate (22.4%) and chlorpheniramine maleate (CPM) (11.2%); and Benzodiazepines: lorazepam (6.5%). Three factors that significantly influenced prescribing of PIMs were polypharmacy (adjusted OR 3.51; 95% CI 2.81-4.32), having ≥3 chronic diseases (adjusted OR 1.44; 95% CI 1.04-2.01), and age ≥75 years (adjusted OR 1.18; 95% CI 1.01-1.38). Conclusion More than two-thirds of elderly Thai patients in the primary care settings were prescribed PIMs. Multidisciplinary prescription review and PIM screening in patients aged ≥75 years who have ≥3 chronic diseases or polypharmacy should be implemented in primary care and supportive computerized PIMs alert system is needed.

Sex Differences in Potentially Inappropriate Prescribing Among Older Adults With Multimorbidity

Sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns are not well understood. This study sought to identify sex specific risk of PIMs in older adults with cardiovascular-metabolic patterns. Secondary analysis of the Health and Retirement Study interview data (2004-2014; n=6,341, ≥65 y/o) linked to Medicare claims data was conducted. Four multimorbidity patterns were identified based on the list of 20 chronic conditions and included: ‘cardiovascular-metabolic only’, ‘cardiovascular-metabolic plus other physical conditions’, ‘cardiovascular-metabolic plus mental conditions’, and ‘no cardiovascular-metabolic disease’ patterns. Presence of PIM prescribing was identified using the 2015 American Geriatrics Society Beers Criteria, limited to the list of medications to avoid in older adults. Chi-square tests and logistic regressions were used to identify sex differences in prescribing PIMs across multimorbidity patterns: (1) for PIMs overall and (2) for each PIM drug class. Results indicate that on average women were prescribed PIMs more often than men (39.4% and 32.8%, respectively). Women with cardiovascular-metabolic plus other physical patterns (Adj.OR=1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj.OR=1.25, 95% CI: 1.06-1.48) had higher odds of PIM compared to men, however, there were no sex differences in PIM prescribing in the cardiovascular-metabolic only patterns (Adj.OR=1.13, 95% CI: 0.79-1.62). There was variation by sex across different PIM drug classes. Our study emphasizes the need to further reduce PIM prescribing among older adults, and identifies target populations for potential interventions to improve medication prescribing practices.

Continue or not to continue? Attitudes towards deprescription among community-dwelling older adults in China

Inappropriate prescribing of medications and polypharmacy among older adults could lead to avoidable harms. It is hence vital to stop potentially inappropriate medications in this vulnerable group. An approach coined ‘deprescribing’ has been used to describe a patient-centerd process of optimizing medication regimens. But patient resistance to discontinuing medication use is a significant barrier to deprescribing. The present study aims to describe attitudes towards deprescribing and to examine individual-based characteristics that might be associated with these attitudes among community-dwelling older adults in China. We conducted a cross-sectional study through in-person interviews using the validated Patients’ Attitudes Towards Deprescribing questionnaire in two communities through the community-based physical examination platform. Participants were 65 years and older and had at least one chronic disease and one regular prescription medication. Of the 1,897 participants in the study, the average age was 74 years and 1,023 (53.9%) were women. The majority had one chronic disease (n=1,364 [71.9%]) and took 1-2 medications (n=1,483 [78.2%]). A total of 947 (50.0%) older adults reported being willing to stop taking one or more of their medicines if their physician said it was possible, and 1204 (63.5%) older adults wanted to stop a medicine been taking for a long time. Chronological age, marital status, number of chronic diseases, and self-rated health status were associated with the attitudes towards deprescribing. This study showed that half of the participants were willing to cease a medication that their physician though was no longer required. Individual-level factors were associated with attitudes towards deprescribing.

Intervention Design With Cognitively Impaired Populations: The Optimize Deprescribing Intervention

Older adults with cognitive impairment and multiple other chronic conditions often have polypharmacy which increases their risks of medication related cognitive effects, adverse drug events, hospitalization and death and leads to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes for those older adults with cognitive impairment and multiple chronic conditions. The OPTIMIZE trial examined whether a primary care-based, patient- and family-centered intervention educating and activating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and potentially inappropriate medications for older adults with dementia or mild cognitive impairment and multiple chronic conditions. We explored the mechanisms of intervention effectiveness through post hoc qualitative stakeholder interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. All stakeholder groups endorsed the acceptability of the intervention. Success of the intervention was affected by contextual factors including prior knowledge and openness to deprescribing, cognition and prognosis. Positive outcomes included patients and care partners scheduling specific appointments to discuss deprescribing and providers remembering to consider deprescribing in cognitively impaired older adults. Recollection of intervention materials was inconsistent over time but highest shortly after intervention delivery. The time required to mail intervention materials to patients prior to a scheduled appointment limited the reach of the intervention by excluding persons with rapidly scheduled appointments. Our work identifies key learnings in intervention roll out which can guide future translation of our intervention to other settings and other pragmatic intervention studies in this vulnerable population.