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.

Development and Evaluation of a Reliable Medication Management Self-Assessment Checklist.

An ability to effectively self-manage medications is the result of several factors influencing a person's decision to take medications. The need for new approaches to medication self-management are evident in the persistent trends of ineffective medication use and unfortunate consequences, referred to as drug-related morbidity and mortality. Fortunately, pioneering initiatives have emerged to reshape our approach for developing a rational organizational paradigm so that patients can confidently self-manage medications. Favorable outcomes of studies pertaining to the delivery of comprehensive medication therapy management services within the practice of pharmaceutical care prompts the question, 'Can patients and family members apply a consistent and systematic 4-step pharmacotherapy assessment process to better organize their decision-making and confidence in medication self-management?' To answer this question an Effective Medication Self-Management Toolkit based on this 4-step process, and a Medication Management Self-efficacy Checklist, were developed and evaluated for feasibility, acceptability, and internal consistency reliability. The first evaluation established the preliminary acceptability and feasibility of the toolkit using a convenience sample of 39 residents of independent living facilities in focus group sessions. All participants indicated they perceive that the 4-step process can help individuals successfully self-manage medications. At the conclusion of the focus group sessions, all 39 participants completed the 7-item post-session checklist. This paper presents the second evaluation to establish the internal consistency reliability of the toolkit's Medication Management Self-efficacy Checklist using Cronbach's alpha. There was good internal consistency of the self-efficacy checklist with a Cronbach's alpha value of 0.82. This investigation of a novel approach for applying the 4-step pharmacotherapy assessment process by patients suggests that the medication self-efficacy checklist provides a reliable and useful measure of a patient's confidence in self-managing medications.

Standardized direct oral anticoagulants prescription for treatment of acute venous thromboembolism in the emergency department: A quality improvement initiative.

INTRODUCTION: Direct oral anticoagulants (DOACs) are commonly used for the treatment and prevention of venous thromboembolism (VTE). However, prescription errors with DOACs can lead to patient dissatisfaction and harm. This study aimed to evaluate the impact of a standardized prescription for DOACs for VTE on prescription appropriateness. MATERIALS AND METHODS: The study included patients discharged from the Emergency Department (ED) with a DOAC prescription for an acute VTE. A standardized prescription tool was developed and implemented, and patients were divided into pre- and post-intervention groups. The appropriateness of prescriptions was assessed using the Medication Appropriateness Index (MAI). RESULTS: A total of 161 patients with VTE were included in the study. The post-intervention group showed a significant increase in prescriptions with an MAI rating of "appropriate" and a decrease in ratings of "inappropriate." Improvements were observed in loading dose duration, maintenance dose frequency and duration, and inclusion of necessary drug coverage codes. CONCLUSION: The implementation of a standardized prescription for DOACs in the management of VTE in the ED significantly improved medication appropriateness and reduced inappropriate prescriptions. Standardized prescriptions have the potential to enhance patient safety and optimize care by providing clear and uniform guidance to healthcare providers. Further research is needed to explore the effectiveness of medication prescription software systems in real-world clinical settings to improve prescribing practices.

Barriers and facilitators of health professionals in adopting digital health-related tools for medication appropriateness: A systematic review.

Objective: Digital health is described as the use and development of all types of digital technologies to improve health outcomes. It could be used to prevent medication errors, a priority for health systems worldwide. However, the adoption of such tools remains slow. This study aims to identify factors (attitudes, knowledge and beliefs) acting as barriers and/or facilitators reported by healthcare professionals (HCPs) for the adoption of digital health-related tools for medication appropriateness. Methods: A systematic review was performed by searching the literature in the MEDLINE PubMed, and EMBASE scientific databases for original articles regarding qualitative and quantitative data. Results: Fifteen articles were included and a total of 125 barriers and 108 facilitators were identified, consolidated and categorized into technical (n = 48), organizational (n = 12), economical (n = 4), user-related (n = 34), and patient-related (n = 8) components. The most often reported barriers and facilitators were technical component-related ones concerning the need for additional training (n = 6), the time consumed (n = 6), and the easy way of using or learning how to use the tools (n = 9), respectively. Regarding setting analysis, agreement with clinical decision recommendations and impact on the doctor-patient relationship were more valued in primary care, while the user interface and system design were in the hospital. Conclusions: The barriers and facilitators identified in this study provide relevant information to developers and it can be used as a starting point for the designing of successful digital health-related tools, specifically related to medication appropriateness. Future research includes economic evaluation-focused studies and in-depth case studies of specific barriers and facilitators.

Assessment of medication discrepancy, medication appropriateness, and cost analysis among patients with pediatric nephrotic syndrome: An ambispective cohort observational study.

BACKGROUND: Nephrotic syndrome (NS) is a commonly encountered chronic kidney disease in pediatric populations, with South Asian children being at high risk and requiring long-term pharmacological management. Thus, identifying medication discrepancies and evaluating the appropriateness of therapy and its economic burden are vital for inpatient management. The aim of the study was to assess medication reconciliation, medication appropriateness, and cost analysis in NS cases. METHODS: An ambispective cohort observational study was carried out with 150 NS patients where medication discrepancies were identified retrospectively and prospectively using the best possible medication history and following up patients correspondingly. Further, the Medication Appropriateness Index and cost variation analysis were used to assess the prescribed therapy and cost analysis, respectively. RESULTS: Out of 150 patients with NS included, 67.3% were male and the mean age was 7.2 years. In total, 36.7% medication discrepancies were found at baseline and 6% discrepancies at follow-up. The majority of discrepancies were unintentional and due to dosing error both at baseline and follow-up. Further, in only 2% of the patients was there inappropriately prescribed medication, and the majority of patients spent between INR (Indian Rupees) 500 and 1000. CONCLUSION: Chronic conditions like NS require continuous monitoring by the specialist pediatric clinical pharmacist, who can contribute significantly by minimizing the medication discrepancies, by assessing the appropriateness of therapy, and lessening the economic burden.

Polypharmacy and Deprescribing in Older Adults.

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Assessing feasibility of a novel approach to effective medication self-management for older persons.

The fact that nearly one-half of patients take medications differently than as prescribed, combined with the predisposition of older persons to adverse events, suggests a need for new strategies supporting medication self-management for older persons. This pilot study describes the development, acceptability and feasibility of a novel toolkit approach focusing on a systematic 4-step process for ensuring medication appropriateness. A preliminary qualitative assessment of the toolkit's acceptability and feasibility was carried out using a convenience sample of 39 residents aged 62-97 years in two senior living facilities convened in focus groups. A facilitator guided participants through discussions of the 4-step process. All participants indicated they perceive that the toolkit's systematic 4-step process can help older persons successfully self-manage medications. The most common medication use challenges cited by participants were related to effectiveness (35%), followed by intended medical use (27%), safety (23%), and ability to take medications (15%). This preliminary investigation suggests that older adults resonate with use of this 4-step process to confidently self-manage medications and find it feasible and acceptable to use in assessing the appropriateness of their medications. More research is needed to establish the reliability and validity of this toolkit with more diverse populations of older adults.

Clinical Associations with the differences in rivaroxaban dosing in patients with atrial fibrillation stratified by three renal function formulae.

Background: Clinical trials used Cockcroft-Gault (CG) formula to calculate the estimated glomerular filtration rate (eGFR) in order to dose rivaroxaban for patients with atrial fibrillation (AF). Objectives: The aim of this study is to evaluate rivaroxaban dosing appropriateness in patients with AF with or without renal impairment based on the CG formula and other formulae, including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) Study equation and the associated clinical outcomes. Methodology: A retrospective cohort study conducted at Sultan Qaboos University Hospital (SQUH) from 1st January 2016 to 31st December 2020, included all adult patients (≥ 18 years) treated with rivaroxaban for AF and followed up for one year after starting the treatment. Results: Based on the CG formula, the rivaroxaban dose was inappropriately prescribed in 27% of the patients (21% overdosed and 6% underdosed). Higher baseline creatinine (P=0.0014) and concurrent use of antiplatelet therapy (P<0.001) were associated with the tendency to rivaroxaban overdosing. Higher Body Mass Index (BMI) (P=0.002), female sex (P=0.032), and CKD (P=0.003) were associated with rivaroxaban underdosing. The degree of agreement between the renal function tests when comparing MDRD vs CG and CKD-EPI vs CG in terms of estimated glomerular filtration rate/creatine clearance (eGFR/CrCl) calculation was moderate (κ=0.46) and poor (κ=0.00), respectively, while, in terms of rivaroxaban dose appropriateness was almost perfect (κ=0.82) and substantial (κ=0.77). Clinical outcomes measured by stroke and bleeding events were not significantly different according to the appropriateness of the rivaroxaban dose. Conclusion: This study has shown a relatively high consistency with the gold standard in dosing rivaroxaban in AF patients using CG formula. Treatment efficiency and safety were not affected by the proportion of dose inappropriateness found in this cohort.

The Clinical Associations With The Differences in Rivaroxaban Dosing in Patients with Atrial Fibrillation Stratified by three Renal Function Formulae

Background: Clinical trials used Cockcroft-Gault (CG) formula to calculate the estimated glomerular filtration rate (eGFR) in order to dose rivaroxaban for patients with atrial fibrillation (AF). Objectives: The aim of this study is to evaluate rivaroxaban dosing appropriateness in patients with AF with or without renal impairment based on the CG formula and other formulae, including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) Study equation and the associated clinical outcomes. Methodology: A retrospective cohort study conducted at Sultan Qaboos University Hospital (SQUH) from 1st January 2016 to 31st December 2020, included all adult patients (≥ 18 years) treated with rivaroxaban for AF and followed up for one year after starting the treatment. Results: Based on the CG formula, the rivaroxaban dose was inappropriately prescribed in 27% of the patients (21% overdosed and 6% underdosed). Higher baseline creatinine (P=0.0014) and concurrent use of antiplatelet therapy (P<0.001) were associated with the tendency to rivaroxaban overdosing. Higher Body Mass Index (BMI) (P=0.002), female sex (P=0.032), and CKD (P=0.003) were associated with rivaroxaban underdosing. The degree of agreement between the renal function tests when comparing MDRD vs CG and CKD-EPI vs CG in terms of estimated glomerular filtration rate/creatine clearance (eGFR/CrCl) calculation was moderate (κ=0.46) and poor (κ=0.00), respectively, while, in terms of rivaroxaban dose appropriateness was almost perfect (κ=0.82) and substantial (κ=0.77). Clinical outcomes measured by stroke and bleeding events were not significantly different according to the appropriateness of the rivaroxaban dose. (AU)

A pilot study about methods to reduce prescription errors in a chemotherapy day unit - Aspects to consider in pharmacist verification process.

INTRODUCTION: Prescribing errors can happen unintentionally during the prescribing process, or when choosing a treatment therapy. Prescribing errors have the highest prevalence amongst common error types related to chemotherapy medication in outpatient settings. According to the Joint Commission International (JCI), prescriptions should be reviewed for appropriateness by someone else than the prescriber or practitioner to prevent medication errors. AIM: The study was aimed to map out the existing type and amount of occurring deviations in prescribing and to clarify the current chemotherapy prescribing practices at the Comprehensive Cancer Center at Helsinki University Hospital. Similar research has not been published in Finland before. METHODS AND PATIENTS: The researcher selected patients randomly from the daily outpatient attendance list following a predetermined numerical order. Data was collected by conducting a medication verification review in line with the JCI guidance by a clinical pharmacist the day before the patient's clinic appointment using the available medical documentation. A clinical pharmacist evaluated findings from prescriptions and contacted an oncologist if the findings were considered clinically significant. RESULTS: A clinical pharmacist verified prescriptions from 101 patients for appropriateness and found discrepancies in four percent of the prescriptions (n = 4/101). The oncologist approved 50 percent of the suggested amendments by the pharmacist as clinically significant (n = 2/4). The study revealed that patient's regular home medications were not always correctly recorded into the database, so verification of medicine interactions could not be trusted as completely accurate. It took on average 16 min per patient to perform a medication verification review. The process was slowed down by the lack of detailed enough protocols for this purpose and the current patient care record system not having structural formatting of data entry. CONCLUSIONS: Verification of prescriptions provides a tool to identify prescribing discrepancies and to prevent unintended medication errors affecting patients. The development of detailed protocols and guidelines, as well as an appropriate training program, would support pharmacists in compiling clinical medication reviews for chemotherapy patients. More research is needed to further develop the operating model in Finland. Information gathered from this study can be used for identifying training requirements.

Effect of pharmacist intervention on antibiotic prophylaxis in orthopedic internal fixation: A retrospective study.

BACKGROUND: Despite the availability of guidelines and official policies, antibiotic prophylaxis in clean surgery remains suboptimal. OBJECTIVE: The aim of this study was to evaluate the clinical effects and cost-effectiveness of pharmacist-led intervention in the perioperative anti-infection prophylaxis of patients undergoing orthopedic internal fixation. METHODS: We performed a retrospective analysis based on the medical records of internal fixation surgery in a tertiary hospital from July 2019 to June 2020. Data were divided into two groups based on whether a full-time pharmacist participated in the treatment. The research parameters included use of antibiotics, rationality of medication, postoperative complications, and related cost. To deal with selection bias, propensity score matching method was employed at a ratio of 1:1. Meanwhile, a cost-effectiveness analysis was used to evaluate the impact of pharmacist intervention on antibiotic prevention in internal fixation surgery. RESULTS: A total of 537 participants were included in this study. After matching, 236 patients were comparable in each group. During the pharmacist intervention period, less pharmacologic prophylaxis (96.6% vs 100.0%, p = 0.007) and shorter prophylaxis duration (1.60 vs 2.28 days, p < 0.001) were observed. The reasonable rate increased dramatically in usage and dosage (96.6% vs 83.9%, p < 0.001), timing of administration (94.5% vs 78.4%, p < 0.001) and medication duration (64.4% vs 37.7%, p < 0.001). In addition, pharmacist intervention yielded net economic benefits. A remarkable reduction was observed in average length of stay (10.43 vs 11.14 days, p = 0.012), drug cost ($610.57 vs $706.60, p = 0.001) and defined daily doses (2.31 vs 3.27, p < 0.001). The cost-effectiveness ratios, divided drug cost savings by cost of pharmacist time, were 28:1 for drug and 2:1 for antibiotics, respectively. CONCLUSION: Pharmacist-driven antibiotic stewardship for orthopedic internal fixation patients improved compliance with peri-procedure antibiotic prophylaxis, and reduced the cost and utilization of antibiotics. This helped to bring significant clinical and economic benefits.

A Pharmacoeconomic Study of Respiratory Medications for Hospice Patients with End-Stage Respiratory Disease.

Background: End-stage respiratory disease and compromised clinical status can hinder patients' ability to use inhalers for effective symptom management. Nebulized and oral medications offer an alternative drug delivery method that may provide therapeutic benefits and reduce medication expenditure. Objectives: Primary research objectives were to determine the cost per patient per claim per day for inhaler devices, nebulized medications, or oral corticosteroids and to estimate the monetary waste generated by using inhalers at the end of life. Design: A retrospective pharmacoeconomic analysis of claims adjudicated by a national hospice-centric pharmacy benefit manager between January 1, 2017, and December 31, 2019. Setting/Subjects: A total of 37,935 adult patients (aged ≥18 years) admitted to hospice with a primary diagnosis of end-stage respiratory disease in the United States were included in the study. Results: A total of 295,451 claims for inhalers, nebulized medications, and oral corticosteroids were analyzed. The mean costs per patient per claim per day were $10.64 for inhalers, $3.28 for nebulized medications, and $1.02 for oral corticosteroids. These costs were significantly different from each other (all p values <0.001). Total monetary waste resulting from unused inhaler doses was $1,040,669, with 21.0%, 13.1%, and 7.3% of patients having claims for inhalers within 30, 14, and 7 days of discharge, respectively. Conclusions: Inhaler use near the end of life generates a significant amount of monetary waste. Using a combination of nebulized and oral medications could reduce health care costs. Nebulized medications may generate less waste since providers can tailor the dispensed supply to the patient's needs rather than using the standard one-month supply of inhaler devices.

Medication Use and Costs Among Older Adults Aged 90 Years and Older in Italy.

Older adults are often affected by multiple chronic conditions and experience geriatric syndromes that may affect the risk/benefit profile of medications. Little is known about the use of such medications in the older population. This article describes medication use and costs in Italian adults aged ≥90 years. Data from the 2019 Pharmaceutical Prescriptions database, concerning data on medications reimbursed by the Italian National Health Service, were analyzed in terms of prevalence and amount of use expressed as defined daily dose/1,000 users (DDD/1,000 users/day), accounting for different age-groups and sex. All individuals aged ≥90 years used at least one medication, with a mean number of 3128 DDD/1,000 users/day corresponding to an annual cost of 683 euros per user. Both use and costs linearly decreased with increasing age, with men accounting for a higher amount of DDD/1,000 users and costs than women across all age-groups. Antihypertensives (1330 DDD/1,000 inhabitants), antiplatelet agents (337 DDD/1,000 inhabitants), medications for peptic ulcer and gastroesophageal reflux (328 DDD/1,000 inhabitants), and lipid-lowering agents (166 DDD/1,000 inhabitants) were the most frequently used medications. We observed a progressive decrease in the usage of the majority of medications with increasing age, with the exception of antibiotics and antipsychotics. Individuals aged ≥90 years used a lower DDD/1,000 users, with an associated decrease in annual costs. The persistent use of preventive medications highlights the potential lack of awareness regarding medication rationalization and guidance for optimizing prescriptions. Our findings highlight the need for further initiatives to improve medications' appropriateness in these older age-groups.

Clinical pharmacist evaluation of medication inappropriateness in a geriatric hospital.

BACKGROUND: Potentially inappropriate prescribing (PIP) in elderly patients is highly prevalent and is associated with an increased risk of adverse drug events, morbidity, and mortality. Accordingly, this study aimed to evaluate the PIP encountered in a geriatric setting and to highlight the role of the clinical pharmacists in this context. METHOD: A retrospective observational study was conducted during March and April 2018 in an elderly daycare in Beirut area. Patients' files were screened to evaluate each patient's clinical status using a developed tool that included the Medication Appropriateness Index. Statistical analysis was performed using SPSS (version 20). The results were considered significant at P<0.05. RESULTS: The results showed a high incidence of hypertension, schizophrenia, and diabetes among the studied sample with percentages of 41.7%, 35.3%, and 26.6%, respectively. As for the PIP, drug therapy duration and cost were the most encountered problems followed by medication indication, dosage, and drug-drug interaction. Moreover, PIP increased with the number of prescribed medications (P<0.05). Proton pump inhibitors, low dose aspirin, and antidiabetic medications' users had a significantly higher Medication Appropriateness Index score as compared to non-users. CONCLUSION: As a conclusion, suboptimal care is proved in this study empowering the collaboration between clinical pharmacists and physicians in minimizing the PIPs in elderly daycares.

Use of Statins in Kidney Transplant Recipients in Norway.

Kidney transplant recipients (KTRs) experience increased risk of cardiovascular disease. Guidelines recommend HMG-CoA reductase inhibitor (statin) therapy when tolerated. We aimed to study changes in the prescription of statins and patients' adherence to treatment over time. A population-based observational study utilizing linked data from the Norwegian Renal Registry (national coverage of 99.9%) and the Norwegian Prescription Database was performed. Data from a total of 2250 first KTRs were included (mean age-54 years, 69% men). Dispensed prescriptions of statins and immunosuppressants for the period 2004-2016 for all first KTRs engrafted in the period 2005-2015 were analyzed. Seventy-two percent received statins the first year after kidney transplantation and the proportion increased with age. The proportion receiving a statin varied according to the time frame of transplantation (77% in 2005-2010 vs. 66% in 2012-2015). Among new users of statins, 82% of the patients were adherent both the second and third year after kidney transplantation, while the corresponding figure for those already receiving statins before transplantation was 97%. Statin continuation rates in KTRs were high. In conclusion, our findings show a slightly lower overall proportion of patients receiving statins after kidney transplants than the national target level of 80%. The proportion of statin users increased with the age of the KTRs but showed a decreasing trend as time progressed.

Study on the feasibility of pharmaceutical intervention to improve medication appropriateness in elderly inpatients / 中国药房

OBJECTIVE To evaluate the effects of pharmaceutical interventio n led by clinical pharmacists on medication appropriateness of elderly inpatients. METHODS A non-randomized concurrent controlled trial was carried out. Elderly patients admitted to two treatment groups in the geriatric department of Yancheng First People ’s Hospital since June 2021 were selected as the research objects. According to the inclusion and exclusion criteria ，the first 40 patients were selected from each of the two treatment groups （according to the order of admission time ）and set as the control group or the intervention group. The control group received routine treatment and nursing services ，and the intervention group additionally received pharmaceutical intervention led by clinical pharmacists on the basis control group. Clinical pharmacists found potential inappropriate medication （PIM）and put forward suggestions on optimization of medication regimen. American Geriatrics Society 2019 Updated AGS Beers Criteria ® for PIM Use in Older Adults （hereinafter referred to as “Beers criteria ”）and the Criteria of PIMs for Older Adults in China 2017 Edition （hereinafter referred to as “Chinese criteria ”）were used as reference tools for drug use review. The medication appropriateness index （MAI）total scores （main evaluation indicator ），the number of PIMs ，the number of drugs used ，the length of hospital stay ，the number of drug-related adverse events during hospital stay ，the number of drug regimen optimization suggestions by pharmacists ， and implementation rate of E-mail：zhihuadou@163.com optimization suggestions adopted by clinicians were compared between 2 groups at admission and at discharge. RESULTS At admission ，there were no statistically differences in MAI total scores，the number of PIMs based on Beers criteria ，the number of PIMs based on Chinese criteria or the number of drugs used between 2 groups（P＞0.05）. At discharge ，there were no statistically differences in the number of PIMs based on Chinese criteria and the length of hospital stay between 2 groups（P＞0.05），but the MAI total scores ，the number of PIMs based on Beers criteria and the number of drugs used in the intervention group were lower than those in the control group （P＜0.05）. In the intervention group，the proportion of drugs recorded as “inappropriate medication ”at admission （34.5％）was significantly higher than that at discharge（19.5％）（P＜0.05）. The difference between the number of drugs discharged from hospital and the number of drugs admitted to hospital in the control group [ 3（1-4.8)] was significantly higher than that in the intervention group [ 1（0-2.8)]（P＝ 0.012）. Compared with admission ，the proportion of drugs recorded as “inappropriate medication ”in the intervention group at discharge was significantly decreased on the basis of “effectiveness”dimension and “course”dimension （P＜0.05）. During hospitalization，clinical pharmacists put forward 70 optimization suggestions of drug regimen for the intervention group ，among which 39 suggestions were adopted and implemented by clinicians ，with an implementation rate of 55.7％. CONCLUSIONS The pharmaceutical intervention led by clinical pharmacists can improve overall appropriateness of drug use in the elderly inpatients using MAI as main evaluation indicator.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: A systematic review of randomized trials and non-randomized intervention studies.

BACKGROUND: Polipharmacy has been identified as a contributing factor to the high hospital readmission rates of heart failure (HF) patients. Nevertheless, there limited evidence on pharmacist-led intervention on the reduction of inappropriate medication use in patients. OBJECTIVE: To summarize the available evidence resulting from interventions, led by pharmacists (alone or as part of a professional team), aimed at reducing inappropriate medications in patients with heart failure. METHODS: A systematic review was conducted using MEDLINE through PubMed, Embase, the Cochrane Library and Scopus until June 2020. We reviewed both randomized controlled trials and non-randomized intervention studies.The quality of evidence was assessed in accordance with the modified Cochrane Collaboration tool to assess risk of bias for randomized controlled trials. The search and extraction process followed PRISMA guidelines. RESULTS: Of the 4367 records screening, 9 studies were included in the analysis. In 4 (44.4%) studies, the intervention was carried out by a pharmacist working together with a physician; in 4 (44.4%) the intervention was carried out by a pharmacist alone, and in 1 study, the pharmacist collaborated with a nurse. Only 5 (55.5%) studies described the utilization of guidelines or recommendations to carry out the deprescription, and 3 of these showed improved clinical outcomes in the interventional group compared to the control group. The other studies (4, 44.4%) did not follow a specific guideline or recommendation to evaluate the appropriateness of medication, and none of them showed statistically significant differences in clinical outcomes between interventional and control groups. CONCLUSION: Only those studies where pharmacists evaluated the appropriateness of treatment to specific HF guidelines showed significant differences in patients' clinical outcomes. The development and validation of a specific tool to evaluate medication appropriateness in patients with HF, could contribute to the improvement of patient health.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life.

PURPOSE OF REVIEW: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). RECENT FINDINGS: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. SUMMARY: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

An evaluation of medication appropriateness in pregnant women with coexisting illness in a tertiary care hospital.

AIM: Prescribing drugs during pregnancy needs careful consideration of benefit to the mother and risk to the fetus. Therefore, this study was conducted to evaluate the appropriateness of medications among pregnant women with coexisting illness in a tertiary care hospital, Western India. MATERIALS AND METHODS: It was a hospital-based cross-sectional study conducted in the obstetrics and gynecology department of a tertiary care hospital. The study was conducted over a period of 12 months wherein data from 800 pregnant women suffering from any co-existing illness and being prescribed any medication apart from routine supplementation were analyzed. The Medication Appropriateness Index (MAI) was used to assess the appropriateness of medications. Higher MAI scores indicate more inappropriate prescribing. RESULTS: Drugs which were most inappropriately prescribed with the highest average MAI scores were albendazole, itraconazole, injection amikacin, oxcarbazepine, warfarin, domperidone, propylthiouracil, and combiflam (ibuprofen + paracetamol). Diseases with the highest average MAI scores were anemia, Grave's disease, umbilical hernia, urinary tract infection, urticaria, allergic rhinitis, and preeclampsia. The MAI criteria which had the highest percentage of inappropriately prescribed medications were "cost of drugs," "duration of therapy," and "indication." CONCLUSION: Potentially inappropriate prescribing was seen in the study with some of the common coexisting illness being treated with drugs which fared poorly on the MAI. The study has also highlighted areas in drug prescribing where scope for improvement exists. Further, it can act as a benchmark for comparison of future studies to evaluate medication appropriateness in pregnant women.