How to Mitigate Community Harms of Antibacterial Resistance With Patient-Centered Care.

Overprescription of antibiotics in cases in which bacterial infection is clinically uncertain contributes to increased prevalence of multidrug-resistant bacteria. Ethically, merits and drawbacks of stricter prescription practice oversight should be weighed against risks of untreatable bacterial infections to patients and communities. This article considers how to balance this set of ideas and values.

Examining Antimicrobial Stewardship Program Implementation in Carceral Settings.

Antimicrobial resistance is a global threat that inequitably affects minoritized populations, including Black, Latinx, and Indigenous people-especially in carceral settings-and is largely driven by inappropriate antimicrobial prescribing practices. People whose identities are minoritized are more likely to be incarcerated, and people who are incarcerated experience higher disease risk than people who are not incarcerated. This article draws on a case of dental infection suffered by a woman who is incarcerated to consider key ethical and clinical complexities of antimicrobial prescribing in carceral settings.

Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge.

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy. STUDY DESIGN: We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors. RESULT: 3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001). CONCLUSION: The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

Lists of potentially inappropriate medications for older people in primary care: a systematic review of health outcomes.

This study is a systematic literature review of the association between lists of potentially inappropriate medications (PIM) in clinical practice and health outcomes of older adults followed up in primary health care. For this purpose, the PRISMA protocol was used to systematize the search for articles in the PubMed, Web of Science, Scopus, Cochrane Central, LIVIVO and LILACS databases, in addition to the gray literature. Studies with randomized clinical trials were selected, using explicit criteria (lists) for the identification and management of PIM in prescriptions of older patients in primary care. Of the 2,400 articles found, six were used for data extraction. The interventions resulted in significant reductions in the number of PIM and adverse drug events and, consequently, in potentially inappropriate prescriptions (PIP) in polymedicated older adults. However, there were no significant effects of the interventions on negative clinical outcomes, such as emergency room visits, hospitalizations and death, or on improving the health status of the older adults. The use of PIM lists promotes adequate medication prescriptions for older adults in primary health care, but further studies are needed to determine the impact of reducing PIM on primary clinical outcomes.

Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks.

INTRODUCTION: Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED: Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION: Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.

Deprescribing: An umbrella review.

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review.

INTRODUCTION: Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention. OBJECTIVES: To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions. DESIGN: We performed a scoping review as defined by the Joanna Briggs Institute. SETTING: The focus was on primary care settings. DATA SOURCES: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024. ELIGIBILITY CRITERIA: We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded. EXTRACTION AND ANALYSIS: We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions. RESULTS: In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention. CONCLUSIONS: Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

Structured medication reviews for adults with multimorbidity and polypharmacy in primary care: a systematic review protocol.

INTRODUCTION: Polypharmacy is common among individuals with multimorbidity, often leading to inappropriate medication use and is associated with an increased risk of frailty, hospitalisation and mortality. Structured medication reviews (SMRs) have emerged as a promising method for optimising medication use. However, research examining their efficacy is limited. This review aims to evaluate the impact of SMRs on improving outcomes for adults with multimorbidity and polypharmacy in primary care settings. Additionally, this review seeks to identify prevailing patterns and trends in the mode of delivery of SMRs. METHODS AND ANALYSIS: A systematic review will be conducted using Ovid MEDLINE, Ovid EMBASE, Web of Science and CINAHL (1997-present). Primary outcomes will include medication-related measures such as dose, frequency and dosage form. Secondary outcomes under investigation will include physical, mental, functional and health service outcomes, as reported. Two independent reviewers will conduct the screening and data extraction, resolving disagreements through discussion. Once eligible studies are identified, the extracted data will be summarised in tabular format. The risk of bias in the articles will be assessed using either the Cochrane Risk of Bias 2 tool or the Newcastle-Ottawa scale, depending on the design of the studies retrieved. Subgroup analysis will be performed using demographic variables and modes of delivery where the data supports. If appropriate, a meta-analysis of the data extracted will be conducted to determine the impact of the SMRs on reported outcomes. If a meta-analysis is not possible due to heterogeneity, a narrative synthesis approach will be adopted. ETHICS AND DISSEMINATION: This proposed review is exempt from ethical approval as it aims to collate and summarise peer-reviewed, published evidence. This protocol and the subsequent review will be disseminated in peer-reviewed journals, conferences and patient-led lay summaries. PROSPERO REGISTRATION NUMBER: CRD42023454965.

Managing polypharmacy through medication review tools - pros and cons.

Inappropriate polypharmacy is a common occurrence in elderly patients, resulting in increased adverse drug reactions, nonadherence, and increased healthcare costs. Medication review and deprescribing are the primary strategies described in the literature for dealing with problematic polypharmacy. To effectively carry out the medication review, various tools have been developed. These tools can support medication review in a variety of ways. Some tools include a list of medications requiring detailed attention, while others guide medical professionals with principles and algorithms for reviewing and prescribing medicines. A third category of tools focuses on tracking and identifying symptoms that may be due to drug-related problems.

Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method.

BACKGROUND: Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. METHODS: We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. RESULTS: The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. CONCLUSIONS: Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

Hungarian general practice paediatricians' antibiotic prescribing behaviour for suspected respiratory tract infections: a qualitative study.

OBJECTIVES: Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework. DESIGN: The design is a qualitative study based on individual, semistructured telephone or virtual interviews. SETTING: Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants. PARTICIPANTS: We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city. RESULTS: Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years. CONCLUSIONS: Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration.

BACKGROUND: Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS: We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS: We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS: The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Community pharmacists' awareness, identification, and management of prescribing cascades: A cross-sectional survey.

BACKGROUND: Prescribing cascades can lead to unnecessary medication use, healthcare costs, and patient harm. Pharmacists oversee prescriptions from multiple prescribers and are well positioned to identify such cascades, making pharmacists key stakeholders to address them. OBJECTIVES: To evaluate community pharmacists' awareness, identification, and management of prescribing cascades and to assess behavioural determinants that may be targeted in future strategies to minimise inappropriate prescribing cascades. METHODS: An online survey was developed using the Theoretical Domains Framework (TDF) and emailed to all registered community pharmacists in Ireland (n = 3775) in November 2021. Quantitative data were analysed using descriptive and inferential statistics. Free-text sections were given to capture reasons for non-resolution of identified prescribing cascades and suggestions to aid prescribing cascade identification and management; this text underwent content analysis. RESULTS: Of the 220 respondents, 51% were aware of the term 'prescribing cascade' before the survey, whilst 69% had identified a potentially inappropriate prescribing cascade in practice. Over one third were either slightly confident (26.4%) or not confident at all (10%) in their ability to identify potentially inappropriate prescribing cascades in patients' prescriptions before the survey, whilst 55.2% were concerned that patients were receiving prescribing cascades they had not identified. Most respondents wanted further information/training to help prescribing cascade identification (88.3%) and management (86.1%). Four predominant TDF domains identified were common to both i) influencing non-resolution of identified prescribing cascades and ii) in the suggestions to help identify and manage prescribing cascades: 'Environmental Context and Resources', 'Social/Professional Role and Identity', 'Social Influences' and 'Memory, Attention and Decision Processes'. CONCLUSIONS: There is a clear need to provide additional resources to help community pharmacists identify and manage prescribing cascades. These findings will support the development of theory-informed behaviour change strategies to aid the minimisation of inappropriate prescribing cascades and decrease the risk of medication-related harm for patients.

Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study.

BACKGROUND: Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting. METHODS: A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27. RESULTS: A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0-64.5). CONCLUSIONS: Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders' experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.

Improving Antibiotic Overuse in Primary Care: A Multimodal Quality Improvement Project.

PURPOSE: Antibiotic overuse has increased over time related to provider knowledge gaps about best practices, provider perception of patient expectations on receiving an antibiotic, possible pressure to see patients in a timely fashion, and concerns about decreased patient satisfaction when an antibiotic is not prescribed. The Centers for Disease Control and Prevention estimates that up to 30% of antibiotics are inappropriately prescribed in the outpatient setting. APPROACH: This quality improvement project consisted of a multimodal approach to decrease inappropriate antibiotic prescribing for viral upper respiratory infections (URIs) by using provider education, passive patient education, and clinical decision support tools based on Centers for Disease Control and Prevention recommendations and the Be Antibiotic Aware tool. OUTCOMES: Following implementation, there was an 11% decrease in viral URI antibiotic prescribing, from a rate of 29.33% to 18.33% following the multimodal implementation. CONCLUSION: The use of evidence-based education and treatment guidelines was found to decrease inappropriate antibiotic prescribing for patients diagnosed with viral URIs.