Polypharmacy: Evaluating Risks and Deprescribing.

Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes. There are several risk factors that can lead to polypharmacy. Patient-related factors include having multiple medical conditions managed by multiple subspecialist physicians, having chronic mental health conditions, and residing in a long-term care facility. Systems-level factors include poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics. Tools that help identify potentially inappropriate medication use include the Beers, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to right treatment) criteria, and the Medication Appropriateness Index. No one tool or strategy has been shown to be superior in improving patient-related outcomes and decreasing polypharmacy risks. Monitoring patients' active medication lists and deprescribing any unnecessary medications are recommended to reduce pill burden, the risks of adverse drug events, and financial hardship. Physicians should view deprescribing as a therapeutic intervention similar to initiating clinically appropriate therapy. When deprescribing, physicians should consider patient/ caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to slow disease progression, prevent health decline, and address symptoms. Point-of-care tools can aid physicians in deprescribing and help patients understand the need to decrease medication burden to reduce the risks of polypharmacy.

Reach and Adoption of a Randomized Weight Loss Maintenance Trial in Rural African Americans of Faith: The WORD (Wholeness, Oneness, Righteousness, Deliverance).

PURPOSE: There is minimal information regarding the Reach and Adoption of evidence-based weight loss maintenance interventions for African Americans of faith. DESIGN: The WORD (Wholeness, Oneness, Righteousness, Deliverance) was an 18-month, cluster randomized trial designed to reduce and maintain weight loss in African American adults of faith. Participants received the Diabetes Prevention Program adapted core weight loss program for 6 months, and churches were subsequently randomized to 12-month maintenance treatment or control. All participants underwent body weight and associated behavioral and psychosocial assessments at baseline, 6, 12, and 18 months. The current article focuses on assessing Reach and Adoption at baseline and 6 months using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. SETTING: Lower Mississippi Delta. PARTICIPANTS: Thirty churches, 61 WORD Leaders (WLs), and 426 participants. INTERVENTION: Group delivered by trained community members (WLs). MEASURES: Body mass index and percentage weight lost from baseline to 6-month follow-up were measured. Reach was assessed at participant, WL, and church levels through calculating participation rates and sociodemographics of each level. Adoption was assessed at church and WL levels. ANALYSIS: Descriptive statistics summarized baseline characteristics of each level. Continuous and categorical end point comparisons were made. RESULTS: Participants' participation rate was 0.84 (n = 437 agreed to participate, n = 519 eligible invited to participate); they were predominantly female, employed, and had a mean age of 49.8. Dropouts by 6 months were younger, had differential marital status, and religious attendance compared with retained participants. Church participation rate was 0.63 (n = 30 enrolled, n = 48 eligible approached) and the majority reported ≤100 active members. The WL participation rate was 0.61 (n = 61 implemented intervention, n = 100 eligible approached); they were primarily female and aged 53.9 (mean). CONCLUSION: Recruitment, engagement, and delivery strategies employed by the WORD show promise of sustained engagement and adoption in other faith-based behavioral weight management programs for African Americans.

Innovative utilization of pharmacist-led board review in a family medicine residency curriculum.

BACKGROUND AND PURPOSE: The Society of Teachers of Family Medicine Group on Pharmacotherapy recommends a formal curriculum during family medicine residency training and describes benefits of utilizing pharmacists. Limited literature exists on how programs have incorporated questions from family medicine board preparation sources into pharmacotherapy academic education. The primary objective was to assess the impact on family medicine residents' perceived knowledge after incorporation of board review items into pharmacotherapy sessions. EDUCATIONAL ACTIVITY AND SETTING: Pharmacists affiliated with the University of Alabama Family Medicine Residency program incorporated questions from board preparation sources into monthly interactive pharmacotherapy sessions as part of a didactic curriculum between 2014 and 2016. An anonymous survey was administered for two consecutive years in 2015 and 2016 to assess residents' perceptions of the sessions and utilization of board-type questions as an active learning component. The change in residents' perception of knowledge was quantitatively analyzed and written comments were evaluated for recurring themes. FINDINGS: The cumulative survey response was 78% (68/87). Over 80% of residents reported that pharmacotherapy sessions and the use of board-type questions was quite or very helpful. The percent of residents that rated their knowledge as good or excellent significantly increased after every session compared to baseline. Residents noted the sessions' information, applicability, interactive nature, and relevance as strengths. SUMMARY: Incorporation of board preparation questions into interactive pharmacotherapy sessions was well received and improved residents' perception of pharmacotherapy knowledge. Utilizing this model in a formal pharmacotherapy curriculum taught by pharmacists is beneficial for family medicine resident learners.

Opportunities for Identifying and Addressing Unhealthy Substance Use in Rural Communities: A Commentary on Cucciare et al (2017).

Unhealthy substance use is a public health problem facing rural communities across the United States. Unfortunately, numerous challenges including stigma, perceived need for care, and perceived accessibility of substance use treatment serve as barriers to many rural adults using substances in obtaining the care they need. It is therefore important to examine whether accessing health care options other than substance use treatment is associated with improved substance use. In a recent study published in the American Journal of Drug and Alcohol Abuse, we explored whether use of outpatient medical care (OMC) was associated with reductions in substance use among rural stimulant users over a 3-year period. Overall, the results showed that, among rural adults using stimulants, those with at least one OMC visit had fewer days of alcohol, crack cocaine, and methamphetamine use over time. However, most participants reported not having any use of an OMC over the 3-year period, suggesting the need for identifying innovative opportunities to provide substance use help for persons living in rural settings. In this commentary, we discuss opportunities for detecting and addressing unhealthy substance use in retail clinics, via clergy and pharmacists.

Emergence of Global Antibiotic Resistance.

Antibiotic resistance is a worldwide phenomenon and a global public health crisis. The inappropriate use of antibiotics in the human, animal, food, and agricultural arenas have contributed to the current dilemma. Both gram-positive and gram-negative resistant bacteria have been deemed serious and urgent threats by the Centers for Disease Control and Prevention. The World Health Organization has created a 5-objective global action plan to address antimicrobial resistance and to coordinate numerous international sectors. Antibiotic resistance affects both this generation and the next; thus, related ethical challenges, such as patient autonomy and justice have yet to be fully understood.