Browsing by keyword "deprescribing"
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Deprescribing in Older Adults With Cardiovascular DiseaseDeprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction-a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced. Using a framework to deprescribe, this review addresses the rationale, evidence, and strategies for deprescribing cardiovascular and some noncardiovascular medications.
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Nurses' Perspectives on Family Caregiver Medication Management Support and DeprescribingNurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses' perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
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Perceptions of Statin Discontinuation among Patients with Life-Limiting IllnessBACKGROUND: Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear. OBJECTIVE: The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness. DESIGN: Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used. SETTING/SUBJECTS: Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled. MEASUREMENTS: Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other). RESULTS: Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034]. CONCLUSION: Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.
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Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at AdmissionOBJECTIVES: To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness. DESIGN: Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING: U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092). PARTICIPANTS: Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS: Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses ( < 6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS: Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status. CONCLUSION: Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.
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Statin Pharmacotherapy in U.S. Nursing HomesBackground: Statins have questionable benefits among older adults with life-limiting illness. Statin use is widespread among U.S. older adults, but little is known about use in nursing homes. This dissertation was designed to identify the prevalence and predictors of statin pharmacotherapy use and discontinuation in U.S. nursing homes. Methods: Data sources (2011-2016) included: Minimum Data Set 3.0, Medicare administrative claims data, Provider of Service files, and Dartmouth Atlas files. Analyses included: descriptive statistics, multilevel modeling, and proportional change in cluster variations with adjustments to reduce confounding and model misspecification. Results: Approximately 36% of older adults admitted to U.S. nursing homes between 2015 – 2016 were actively using statins at the time of admission. Among long-stay residents with life-limiting illness, 34% were on statins at one time (2016; aged 65-75 years: 44%, >75 years: 31%). Statin use varied significantly by hospital referral regions, with most variation in the >75 age group. Limiting the sample to statin users, 20% discontinued statins within 30 days of nursing home admission. While discontinuation was positively associated with severity of life-limiting condition, the majority of residents remained on statins 30 days post-admission, including those with a < 6-month prognosis. Conclusion: Statin use is pervasive across US nursing homes and persists with life-limiting illness. Geographic variation appeared to coincide with clinical uncertainty, especially among adults >75 with few national guidelines. More needs to be done to prioritize statin deprescribing in nursing homes with research that identifies ways to facilitate improved patient-provider awareness and engagement in the discontinuation process.
