Identifying and reducing inappropriate aspirin use in primary care.

OBJECTIVE: Recent studies have called into question the safety of aspirin use for the primary prevention of atherosclerotic cardiovascular disease, particularly in older adults. Therefore, the objectives of this study were to (1) develop a systematic approach to identifying patients aged 70 and older taking aspirin for primary prevention, (2) provide patient and provider education about updated literature and recommendations regarding aspirin safety and (3) evaluate the impact of this intervention on aspirin de-prescribing. DESIGN: This was a quality improvement intervention with prospective, longitudinal follow-up. SETTING: This study was conducted in two family medicine practices within an academic medical centre. PARTICIPANTS: Patients aged 70 years and older with aspirin listed on the current medication list. METHODS: This is an electronic medical record-based chart review and educational intervention based on shared decision-making to reduce inappropriate aspirin use in primary practice. A chart review process was developed to identify the clinical indication for aspirin use. Patients taking aspirin for primary prevention were flagged for the primary care providers to review. Multilevel logistic regression models assessed factors affecting aspirin de-prescribing and longitudinal trend. RESULTS: Of 361 patients aged 70 years or older, 145 (40%) were taking aspirin for primary prevention of atherosclerotic cardiovascular disease. After 9 months, aspirin was deprescribed in 42 (29%) of these patients. Patients seen by their providers during the study period had lower odds of having aspirin on their medication list (OR=0.87, 95% CI: 0.81, 0.94) as compared with patients taking aspirin who were not seen by their healthcare provider. CONCLUSION: This is the first study to develop and implement a method of identifying potentially inappropriate aspirin use based on recent clinical evidence highlighting the risk of aspirin use for primary prevention in older adults. Future initiatives can leverage existing electronic medical record platforms to efficiently identify patients and expand these efforts to larger patient populations.

Smoking Cessation Considerations for People with Multiple Sclerosis.

BACKGROUND: Comprehensive care of people with multiple sclerosis integrates disease modifying therapy, symptom management and minimization of risk factors for disease progression. Cigarette smoking is a modifiable risk factor associated with development and progression of disease and increased disability. However, little is known about specific factors that affect smoking cessation in patients with multiple sclerosis or how to integrate smoking cessation into specialized multiple sclerosis care. METHODS: Twenty-nine active smokers with multiple sclerosis were surveyed at the James Q. Miller Multiple Sclerosis clinic at the University of Virginia Health. Demographics, smoking history, multiple sclerosis history, interest in quitting, barriers to quitting and cessation modalities of interest were collected, specifically interest in working with a clinical pharmacist for cessation. RESULTS: Seventy-six percent of individuals believed that there was no relationship between smoking and MS diagnosis and 52% were unaware of any relationship between smoking and disease progression. Less than half of patients (41%) reported receiving counseling from a primary care physician or neurologist about the importance of smoking cessation. Common barriers to quitting included enjoyment of smoking (76%) and cravings (55%). Seventy-six percent of patients expressed interest in utilizing pharmacotherapy and 37% were interested in working closely with a clinical pharmacist. CONCLUSIONS: It is critical that providers caring for patients with multiple sclerosis assess smoking status and educate smokers about the relationship between smoking and disease progression. Efforts should be made to better understand patient-specific barriers to quitting and preferred methods of treatment, including pharmacotherapy and behavioral therapy. A multidisciplinary approach to smoking cessation that includes a clinical pharmacist may aid in the development of individualized care plans with frequent monitoring to improve patient success.