Exploring the value of a multidisciplinary-led medication review for elderly individuals at a long-term care facility performed by four different health-care professions in an equal and closely integrated collaboration.

Background: The increasing population of elderly individuals had led to an increasing number of polypharmacy patients. Polypharmacy increases the risk of adverse drug reactions and hospitalization. One means to combat polypharmacy involves performing medication reviews, which can be conducted by different methods and stakeholders. Objective: The study objective was to explore the value of involving different health-care professions in medication reviews at an equal and closely integrated collaborative physical meeting for elderly individuals at a long-term care facility. A specific focus was to explore the contributions and opinions of the different health-care professionals regarding the medication review process. Materials and Methods: A single case study was applied to perform an in-depth study of a group of health-care professionals performing medication reviews in collaboration. Hence, the study was performed in two settings: 1) the practical execution of medication reviews at a long-term care facility in an interprofessional team and 2) qualitative semi-structured interviews conducted to explore the forms of work done by different professional groups in performing an interdisciplinary medication review. Results: Forty-nine residents from a long-term care facility were included in the study and were offered a medication review. In total, they reported 573 prescriptions, for which 150 changes were recommended by the interprofessional team. At the 3- and 8-month follow-ups, 30.0% and 49.5% of the accepted recommendations had been implemented, respectively. According to the interview, the results reveal that the interdisciplinarity of the interprofessional team was perceived as a great advantage to the results of the medication reviews. Conclusion: The results suggest that performing medication reviews in interprofessional collaboration improves the perceived quality of such reviews with a more complete picture of the residents and their medications, leading to more personalized recommendations and resulting in optimized medication reviews for the individual patients.

Exploration of Symptom Scale as an Outcome for Deprescribing: A Medication Review Study in Nursing Homes.

The use of inappropriate medication is an increasing problem among the elderly, leading to hospitalizations, mortality, adverse effects, and lower quality of life (QoL). Deprescribing interventions (e.g., medication reviews (MRs)) have been examined as a possible remedy for this problem. In order to be able to evaluate the potential benefits and harms of a deprescribing intervention, quality of life (QoL) has increasingly been used as an outcome. The sensitivity of QoL measurements may, however, not be sufficient to detect a change in specific disease symptoms, e.g., a flair-up in symptoms or relief of side effects after deprescribing. Using symptom assessments as an outcome, we might be able to identify and evaluate the adverse effects of overmedication and deprescribing alike. The objective of this study was to explore whether symptom assessment is a feasible and valuable method of evaluating outcomes of MRs among the elderly in nursing homes. To the best of our knowledge, this has not been investigated before. We performed a feasibility study based on an experimental design and conducted MRs for elderly patients in nursing homes. Their symptoms were registered at baseline and at a follow-up 3 months after performing the MR. In total, 86 patients, corresponding to 68% of the included patients, received the MR and completed the symptom questionnaires as well as the QoL measurements at baseline and follow-up, respectively. Forty-eight of these patients had at least one deprescribing recommendation implemented. Overall, a tendency towards the improvement of most symptoms was seen after deprescribing, which correlated with the tendencies observed for the QoL measurements. Remarkably, deprescribing did not cause a deterioration of symptoms or QoL, which might otherwise be expected for patients of this age group, of whom the health is often rapidly declining. In conclusion, it was found that symptom assessments were feasible among nursing home residents and resulted in additional relevant information about the potential benefits and harms of deprescribing. It is thus recommended to further explore the use of symptom assessment as an outcome of deprescribing interventions, e.g., in a controlled trial.

A systematic review of blood eosinophils and continued treatment with inhaled corticosteroids in patients with COPD.

Inhaled corticosteroid (ICS) in patients with chronic obstructive pulmonary disease (COPD) has been debated for 20 years. In our systematic literature review and meta-analysis, we addressed the following: Should patients with COPD and a blood eosinophil count (EOS) of, respectively, a) < 150 cells/µl, b) 150-300 cells/µl, and c) > 300 cells/µl continue treatment with ICS? Protocol registered in PROSPERO (CRD42020178110) and funded by the Danish Health Authority. We searched Medline, Embase, CINAHL and Cochrane Central on 22nd July 2020 for randomized controlled trials (RCT) of ICS treatment in patients with COPD (≥40 years, no current asthma), which analyzed outcomes by EOS count and where >50% of patients used ICS prior. We used the GRADE method. Meta-analyzes for the outcomes were divided into EOS subgroups and analyzed for differences. We identified 11 RCTs with a total of 29,654 patients. A significant difference (p < 0.00001) between the three subgroups' reduction of risk of moderate to severe exacerbation was found. Rate ratios for EOS counts: <150 cells/µL was 0.88 (95%CI: 0.83, 0.94); 150-300 cells/µL was 0.80 (95%CI: 0.69, 0.94); >300 cells/µL was 0.57 (95%CI: 0.49, 0.66). Overall, the certainty of the effect estimates was low to very low due to risk of bias, unexplained heterogeneity, few RCTs, and wide confidence intervals. A clear correlation was demonstrated between effect of continued ICS treatment (number of exacerbations, lung function, and quality of life) and increasing EOS count. Our meta-analyses suggested that treatment with ICS seemed beneficial for everyone except patients with EOS count below 150 cells/µl.

Deprescribing: What is the gold standard? Themes that characterized the discussions at the first Danish symposium on evidence-based deprescribing.

The first Danish symposium on evidence-based deprescribing was held in September 2019. The symposium aimed to increase the awareness of deprescribing in general, to discuss the importance of deprescribing, and, thus, a potential consensus on key issues on a national deprescribing agenda. The invited keynote speaker, Barbara Farrell, from the Bruyére Research Institute, Ottawa, Canada, presented their thorough work on deprescribing guideline development and application. The symposium consisted of two parts: Part 1 concentrated on establishing the need for deprescribing in our society. Part 2 consisted of a panel debate that put the practical application and implementation of deprescribing in perspective to the input from the audience and the structure of the Danish healthcare system. The panelists represented key stakeholders, e.g., clinical pharmacists, general practitioners, hospital doctors, Danish Health Authority representatives, health politicians concerning deprescribing in Denmark. The event allowed 145 participants to discuss the importance of implementing deprescribing in a Danish setting. This commentary highlights and discusses the major themes that characterized the symposium: "why deprescribe?", "deprescribing research" and a theme dedicated to "problems of concern." The emergence of these themes formed the basis for the discussion of new strategies and a proposal for a future gold standard to succeed in deprescribing.

Systematic Medication Review in General Practice by an Interdisciplinary Team: A thorough but Laborious Method to Address Polypharmacy among Elderly Patients.

Polypharmacy increases the risk of hospitalization but may be reduced by medication review. The study objective is to describe and evaluate a method for conducting medication review in general practice by an interdisciplinary medication team of pharmacists and physicians-in this case conducted by a team from the Department of Clinical Pharmacology-based on information concerning medication, diagnosis, relevant laboratory data and medical history supplied by the general practitioner. We discussed the medication review with the patients' general practitioners and received feedback from them regarding acceptance rates of the recommended changes. Ninety-four patients with a total of 1471 prescriptions were included. A medication change was recommended for nearly half of the prescriptions (48%); at least one change of medication was recommended for all patients. The acceptance rate for recommended medication changes was 55%, corresponding to a mean of 4.2 accepted recommendations per patient. For 18% of all 1471 prescriptions, the general practitioner agreed either to discontinue (stop the medication completely) or reduce the dose of the medication. This method is thorough, but since it requires several healthcare professionals, it is rather time-consuming. There is a need to support medication review in general practice, but although this method may be too time consuming in most cases, it may nevertheless prove to be a useful tool managing the most complicated patients.