Primary care clinicians’ use of deprescribing recommendations: A mixed-methods study

Objectiveto explore the effects of a deprescribing intervention on primary care clinicians’ medication-related communication.MethodsA clinical decision support tool provided clinicians in the intervention group with an individualized report regarding potentially inappropriate medications (PIMs), deintensification of diabetes and/or hypertension treatment, and poor adherence/cognition. Participants included 113 Veterans aged ≥ 65 prescribed ≥ 7 medications and their primary care clinicians. Encounters were recorded and analyzed.ResultsBetween 36% and 38% of intervention clinicians discussed PIMs and diabetes mellitus/hypertension deintensification and 94% discussed adherence. PIMs discussions referred to the report and prompted some medication changes. The diabetes mellitus/hypertension and adherence discussions were not prompted by the report but instead arose from enhanced medication reconciliation. Changes in diabetes mellitus/hypertension medications were not made out of overtreatment concerns. There was no deprescribing for nonadherence. Enhanced medication reconciliation also led to discussions about medications not in the report.ConclusionAn individualized report regarding medication appropriateness prompted clinicians to perform a more thorough medication reconciliation and discuss PIMs. It did not prompt chronic care deintensification or deprescribing to enhance adherence.Practice ImplicationsFeedback reports can promote robust medication reconciliation in primary care. Changing clinician practice to achieve deprescribing in chronic disease management will be more challenging.     

The prevalence of herbal medicine home use and concomitant use with pharmaceutical medicines in Jamaica

Ethnopharmacological relevance

The work described in this paper aimed to study the prevalence of herbal medicine use in treating illness and concomitant use with pharmaceutical medicines in Jamaica.

Materials and methods

A survey using a structured questionnaire was administered by a trained interviewer to randomly selected adults in systematically selected households within randomly selected urban and rural clusters. Categorical data analysis was performed using Stata version 10 software.

Results

91.4% (372/407) of selected people agreed to participate. 72.6% (270/372) self-medicated with herbs within the previous year. Commonly treated were illnesses of the respiratory system (RS, 77.8% (210/270)), gastro-intestinal tract (GIT, 53.3% (144/270)) and health maintenance using tonics (29.6% (80/270)). 26.7% (72/270) of respondents used pharmaceuticals concomitantly with medicinal plants. Commonly treated were illnesses of the RS (20.4% (55/270)), GIT (13.7% (37/270)) and hypertension (10.0%(27/270)). 19.4% (14/72) of physicians knew of such practices. There was significant association of herb use with/without drugs with age (p < 0.001), employment status (p < 0.001), religion (p = 0.004), gender (p = 0.02) and educational level (p = 0.031). Thus prevalence of herb use alone was greatest amongst people aged 35-44 and 45-54 years; those employed; Rastafarians; those without health insurance; males and people who had completed secondary education. Whilst prevalence of concomitant herb-drug use was greater amongst people aged 65 years and older; those retired; those of religions other than Rastafarians and Christians, females and people who had attained primary education and below.

Conclusions

Self-medication with herbs in Jamaica is highly prevalent and highest for self-limiting conditions of the RS, GIT and health maintenance with tonics. Concomitant herb and drug use is highest for self-limiting conditions of the RS, GIT and hypertension, and the use of combined therapy highlights the need for investigations on potential drug-herb interactions. Physicians have limited awareness and knowledge of such concomitant usage, further highlighting the need for increased dialogue with patients, knowledge of medicinal plants and their uses and a heightened pharmacovigilance to avoid adversities that may arise from potential drug-herb interactions.     

Deprescribing: Moving beyond barriers and facilitators

Unnecessary polypharmacy continues to be a problem among older adults. The field of deprescribing (planned, supervised process of medication discontinuation) aims to address this problem. Deprescribing is a relatively new field despite having grown substantially in recent years. Much of the early research in this area focused on identifying barriers to and facilitators of deprescribing in clinical practice, which contributed to a large body of work on this topic. However, with continuing research around barriers and facilitators, we need to be mindful to undertake research that builds on existing knowledge, addresses known gaps, and advances the field. Additionally, there is a need in deprescribing research to shift focus to developing ways to address known barriers and harness knowledge of facilitators. That is, translating existing knowledge into strategies and tools that can impact clinical practice and lead to practical and sustained deprescribing efforts.     

用药生活问卷的汉化及其在社区老年多重用药患者中的信效度分析

背景　多重用药负担是影响患者用药信念、用药依从性和用药安全的核心要素,医务人员以患者用药负担为中心进行评估,可及时发现其用药过程中亟需解决的问题、制定科学化的药物干预方案,但目前国内尚且缺乏科学、有效的工具来评价患者多重用药负担。目的　汉化用药生活问卷（LMQ）并分析其在社区老年多重用药患者中的信效度,为明确社区老年多重用药患者用药负担现况提供测量工具。方法　采用正译、校对、回译、专家审核、认知性访谈、预调查对LMQ进行汉化,最终形成了包括8个维度39个条目的中文版LMQ（初始版）。2019年4-8月,采用便利抽样法选取郑州市3家社区卫生服务中心〔郑州市社区卫生服务中心（东二街）、林山寨社区卫生服务中心、高新区科学大道社区卫生服务中心〕下属社区中老年多重用药患者为调查对象。本研究第一阶段收集数据用于探索性因子分析,最终确定样本量为260例;第二阶段用于重测信度评估,重测间隔时间为2~4周,最终确定样本量为30例（从第一阶段患者中采用随机数字表法选取）;第三阶段用于验证性因子分析,最终确定样本量为373例。采用一般资料调查问卷、中文版LMQ（初始版）对其进行调查,评价中文版LMQ（初始版）的信效度。结果　第一阶段共发放问卷260份,回收有效问卷242份,有效回收率为93.1%;第二阶段共发放问卷30份,回收有效问卷30份,有效回收率为100.0%;第三阶段共发放问卷373份,回收有效问卷350份,有效回收率为93.8%。项目分析结果显示,中文版LMQ（初始版）各条目得分与其总分的相关系数为0.317~0.658（P<0.01）;中文版LMQ（初始版）各条目决断值（CR）均>3.0。探索性因子分析结果显示,中文版LMQ（初始版）的KMO值为0.875,Bartlett's球形检验的χ2=8 139.877,P<0.01,表明适合做因子分析;共提取出特征根>1.000的公因子有8个,累积方差贡献率为76.780%,各条目在所属公因子上的载荷量均>0.400。验证性因子分析结果显示,预设模型拟合指标不理想,根据指标提示进行模型修正,添加8条协方差相关关系后,各拟合指标处于可接受范围。内容效度：中文版LMQ（初始版）的条目内容效度指数（I-CVI）为0.86~1.00,问卷内容效度指数（S-CVI）为0.949。信度：中文版LMQ（初始版）的Cronbach's α系数为0.892,各维度的Cronbach's α系数为0.867~0.943;中文版LMQ（初始版）的折半信度为0.817,各维度的折半信度为0.841~0.947;中文版LMQ（初始版）的重测信度为0.904,各维度的重测信度为0.802~0.875。最终形成中文版LMQ,其包括8个维度39个条目,分别为用药态度（7个条目）、实践困难（6个条目）、医患关系（5个条目）、用药效果（5个条目）、干扰日常生活（6个条目）、副作用（4个条目）、用药行为（3个条目）、经济负担（3个条目）。结论　中文版LMQ利用39个条目从用药态度、实践困难、医患关系、用药效果、干扰日常生活、副作用、用药行为及经济负担8个方面了解患者的用药负担,信效度良好,且操作简单、评估较全面、条目通俗易懂,可以有效评估社区老年多重用药患者居家生活过程中各方面的用药负担,并为医务人员制定精准化药物支持干预方案提供测评工具。