Using Deprescribing Practices and the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria to Reduce Harm and Preventable Adverse Drug Events in Older Adults.

OBJECTIVES: Approximately 98% of older Americans are simultaneously taking 5-or more-medications to manage at least 2 chronic conditions. Polypharmacy and the use of potentially inappropriate medications (PIMs) are a concern for older adults because they pose a risk for adverse drug events (ADEs), which are associated with emergency department visits and hospitalizations and are an important patient safety priority. We sought to review the evidence of patient safety practices aimed at reducing preventable ADEs in older adults, specifically (i) deprescribing interventions to reduce polypharmacy and (ii) use of the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) to reduce PIMs. METHODS: We conducted a systematic review of literature published between 2008 and 2018 that studied examined the effect of these interventions to reduce preventable ADEs in older adults. RESULTS: Twenty-six studies and 1 systematic review were included (14 for deprescribing and 12 for STOPP and the systematic review). The deprescribing interventions involved decision support tools, educational interventions, and medication reviews by pharmacists and/or providers. Deprescribing studies primarily examined the effect of interventions on process outcomes and observed reductions in polypharmacy, often significantly. A few studies also examined clinical and economic outcomes. Studies of the use of the STOPP screening criteria most commonly reported changes in PIMs, as well as some economic outcomes. CONCLUSIONS: Deprescribing interventions and interventions using the STOPP criteria seem effective in reducing polypharmacy and PIMs in older adults, respectively. Future research on the effectiveness of these approaches on clinical outcomes, the comparative effectiveness of different multicomponent interventions using these approaches, and how to most effectively implement them to improve uptake and evidence-based care is needed.

Collaborative drug therapy management: case studies of three community-based models of care.

Collaborative drug therapy management agreements are a strategy for expanding the role of pharmacists in team-based care with other providers. However, these agreements have not been widely implemented. This study describes the features of existing provider-pharmacist collaborative drug therapy management practices and identifies the facilitators and barriers to implementing such services in community settings. We conducted in-depth, qualitative interviews in 2012 in a federally qualified health center, an independent pharmacy, and a retail pharmacy chain. Facilitators included 1) ensuring pharmacists were adequately trained; 2) obtaining stakeholder (eg, physician) buy-in; and 3) leveraging academic partners. Barriers included 1) lack of pharmacist compensation; 2) hesitation among providers to trust pharmacists; 3) lack of time and resources; and 4) existing informal collaborations that resulted in reduced interest in formal agreements. The models described in this study could be used to strengthen clinical-community linkages through team-based care, particularly for chronic disease prevention and management.

An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American Study and National Survey of American Life.

OBJECTIVE: . To examine racial-ethnic differences in the endorsement and attribution of psychotic-like symptoms in a nationally representative sample of African-Americans, Asians, Caribbean Blacks, and Latinos living in the USA. DESIGN: Data were drawn from a total of 979 respondents who endorsed psychotic-like symptoms as part of the National Latino and Asian American Study (NLAAS) and the National Survey of American Life (NSAL). We use a mixed qualitative and quantitative analytical approach to examine sociodemographic and ethnic variations in the prevalence and attributions of hallucinations and other psychotic-like symptoms in the NLAAS and NSAL. The lifetime presence of psychotic-like symptoms was assessed using the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) psychotic symptom screener. We used logistic regression models to examine the probability of endorsing the four most frequently occurring thematic categories for psychotic-like experiences by race/ethnicity (n > 100). We used qualitative methods to explore common themes from participant responses to open ended questions on their attributions for psychotic-like symptoms. RESULTS: African-Americans were significantly less likely to endorse visual hallucinations compared to Caribbean Blacks (73.7% and 89.3%, p < .001), but they endorsed auditory hallucinations symptoms more than Caribbean Blacks (43.1% and 25.7, p < .05). Endorsing delusions of reference and thought insertion/withdrawal were more prevalent for Latinos than for African-Americans (11% and 4.7%, p < .05; 6.3% and 2.7%, p < .05, respectively). Attribution themes included: supernatural, ghosts/unidentified beings, death and dying, spirituality or religiosity, premonitions, familial and other. Respondents differed by race/ethnicity in the attributions given to psychotic like symptoms. CONCLUSION: Findings suggest that variations exist by race/ethnicity in both psychotic-like symptom endorsement and in self-reported attributions/understandings for these symptoms on a psychosis screening instrument. Ethnic/racial differences could result from culturally sanctioned beliefs and idioms of distress that deserve more attention in conducting culturally informed and responsive screening, assessment and treatment.

Measuring and monitoring progress toward health equity: local challenges for public health.

To address health disparities, local health departments need high-resolution data on subpopulations and geographic regions, but the quality and availability of these data are often suboptimal. The Boston Public Health Commission and the Los Angeles County Department of Public Health faced challenges in acquiring and using community-level data essential for the design and implementation of programs that can improve the health of those who have social or economic disadvantages. To overcome these challenges, both agencies used practical and innovative strategies for data management and analysis, including augmentation of existing population surveys, the use of combined data sets, and the generation of small-area estimates. These and other strategies show how community-level health data can be analyzed, expanded, and integrated into existing public health surveillance and program infrastructure to inform jurisdictional planning and tailoring of interventions aimed at achieving optimal health for all members of a community.

Perspectives on quality mental health care from Brazilian and Cape Verdean outpatients: implications for effective patient-centered policies and models of care.

Mental health providers are increasingly coming into contact with large and growing multi-racial/ethnic and immigrant patient populations in the United States. Knowledge of patient perspectives on what constitutes quality mental health care is necessary for these providers. The aim of this study was to identify indicators of quality of mental health care that matter most to two underrepresented immigrant patient groups of Portuguese background: Brazilians and Cape Verdeans. A qualitative design was adopted using focus group discussions. Six focus groups of patients (n=24 Brazilians; n=24 Cape Verdeans) who received outpatient mental health treatment through public safety net clinics in the northeast region of the United States were conducted. The Consensual Qualitative Research analytic method allowed us to identify three quality of care domains: provider performance, aspects of mental health care environment, and effectiveness of mental health care treatment. Provider performance was associated with five categories: relational, communication, linguistic, cultural, and technical competencies. Aspects of mental health care environment were linked to two categories: psychosocial and physical environment. Effectiveness of mental health care treatment was related to two categories: therapeutic relationship and treatment outcomes. Study findings provide useful data for the development of more culturally appropriate and effective patient-centered models and policies in mental health care.

Race, Relationships and Trust in Providers among Black Patients with HIV/AIDS.

A trustful patient-provider relationship is a strong predictor of positive outcomes, including treatment adherence and viral suppression, among patients with HIV/AIDS. Understanding factors that inform this relationship is especially relevant for Black patients, who bear a disproportionate burden of HIV morbidity and mortality, and may face challenges associated with seeing providers of a racial/ethnic background that is different from their own. Using data collected through the Enhancing Communication and HIV Outcomes (ECHO) study, we build upon extant research by examining patient and provider characteristics that may influence Black patients' trust in their provider. ECHO data were collected from four ambulatory care sites in Baltimore, Detroit, New York and Portland, Oregon (N=435). Regression analysis results indicate that trust in health care institutions and cultural similarity between patient and provider are strongly associated with patients' trust in their provider. Lower perceived social status, being currently employed, and having an older provider were also related to greater patient-provide trust. These findings can inform interventions to improve trust and reduce disparities in HIV care and outcomes that stem from mistrust among Black patients.

"Just be straight with me:" an exploration of Black patient experiences in initial mental health encounters.

It is advantageous for a clinician to understand how patients feel about their initial encounters, but it can be difficult to discern what is and what is not working. This qualitative, exploratory study is guided by the question, "What happens during an initial mental health encounter between a Black patient and a non-Black provider that leads the patient to describe it as a good or poor experience?" The findings are based on face-to-face, postintake interviews with 14 Black patients seen by 11 non-Black providers as part of the Patient-Provider Encounter Study. The objective is to explore the initial interpersonal interactions between Black patients and their non-Black mental health providers and to better understand how patients come to describe the encounter as good (favorable) or poor (unfavorable). A framework inclusive of 5 specific elements is introduced that maps the patient's conceptualization process about how judgments are made about the encounter. Owing to the naturalistic and exploratory nature of the study, a research hypothesis was not established. Instead, we observed how patients scanned the interaction with the provider, made assessments about their provider, and determined whether their experience was positive or negative. The implications of these findings will help to improve the interactions in mental health settings between minority patients and their providers.

Preferences for relational style with mental health clinicians: a qualitative comparison of African American, Latino and Non-Latino White patients.

The goal of this study is to analyze preferences for relational styles in encounters with mental health providers across racial and ethnic groups. Four primary themes describe what patients want from a mental health provider: listening, understanding, spending time, and managing differences. However, using contextual comparative analysis, the findings explicate how these themes are described differently across African Americans, Latinos, and non-Latino Whites, uncovering important qualitative differences in the meaning of these themes across the groups. The article suggests that closer attention to qualitative preferences for style of interaction with providers may help address disparities in mental health care for racial and ethnic minorities.