Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial.
Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial.
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DOI：
10.1001/jamainternmed.2022.0502
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发表时间：
2022-05-01
影响因子：
39
通讯作者：
Boyd CM
中科院分区：
文献类型：
--
作者：
Bayliss EA;Shetterly SM;Drace ML;Norton JD;Maiyani M;Gleason KS;Sawyer JK;Weffald LA;Green AR;Reeve E;Maciejewski ML;Sheehan OC;Wolff JL;Kraus C;Boyd CM
在初级保健就诊前提高对处方的认识能否减少认知障碍患者可能不适当的长期药物的使用？在这项实用群随机临床试验中，对3012名服用5种及以上药物的认知障碍老年人及其初级保健医生进行了处方化教育，干预诊所和对照诊所的患者在6个月时服用的平均药物数量相似（6.4 vs 6.5）， 6个月后服用1种或更多可能不合适的药物的患者比例相似。教育患者和临床医生在初级保健中减少处方对服用5种或更多长期药物的老年人长期药物的数量或潜在不适当药物的百分比没有影响；研究结果表明，此类干预措施应该针对服用相对较多药物的老年人。患有痴呆症或轻度认知障碍的个体经常患有多种慢性疾病（定义为≥2种慢性疾病）并服用多种药物，这增加了他们发生不良后果的风险。减少处方（减少或停止潜在危害大于潜在益处的药物）可能会降低不良后果的风险。研究提高患者和临床医生对痴呆或轻度认知障碍患者减少不必要或危险药物的潜在认识的有效性。这项实用的、以患者为中心的、为期12个月的集群随机临床试验于2019年4月1日至2020年3月31日在一个非营利性综合医疗服务系统的18个初级保健诊所进行。这项研究包括3012名年龄在65岁或以上的患有痴呆症或轻度认知障碍的成年人，他们有一种或更多的慢性疾病，正在服用5种或更多的长期药物。在初级保健访问之前，向患者邮寄了一份教育小册子和一份关于对处方解除态度的问卷，通知了临床医生，并在每月的临床会议上向临床医生分发了处方解除提示表。开具长期药物的数量和开具1种或更多潜在不适当药物（pim）的个人百分比。在意向治疗基础上进行分析。本研究包括来自9个干预诊所的1433名个体（806名女性[56.2%]，平均[SD]年龄80.1[7.2]岁）和来自9个对照诊所的1579名个体（874名女性[55.4%]，平均[SD]年龄79.9[7.5]岁），符合入选标准。在基线时，两组的长期药物平均（SD）数量相似（干预组为7.0[2.1]，对照组为7.0[2.2]），两组中服用1种或1种以上pim的个体比例相似（干预组1433人中有437人[30.5%]，对照组1579人中有467人[29.6%]）。6个月时，干预组和对照组调整后的平均长期用药次数相似（6.4次[95% CI， 6.3-6.5次]vs 6.5次[95% CI， 6.4-6.6次]；P = .14）。干预组和对照组患者服用1种或1种以上pim的估计百分比相似（17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = 0.08）。在预先计划的亚组分析中，在基线时服用7种或更多长期药物的个体（n = 1434），干预组和对照组之间的校正差异为-0.16 (95% CI, -0.34至0.01)，而服用5至6种药物的个体（n = 1578），干预组与对照组之间的校正差异为-0.03 （95% CI, -0.20至0.13）。28为互动；p =。pim的子组交互为19)。这项针对服用5种或5种以上长期药物的认知障碍老年人及其初级保健临床医生的大规模教育减处方干预表明，效果不大，并没有显著减少长期药物和pim的数量。此类干预措施应针对服用相对较多药物的老年人。本群随机临床试验检验了教育患者和临床医生在痴呆或轻度认知障碍患者中减少不必要或危险药物的可能性的有效性。
Can increasing awareness about deprescribing prior to primary care visits reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment? In this pragmatic cluster randomized clinical trial of deprescribing education for 3012 older adults with cognitive impairment taking 5 or more medications and their primary care clinicians, patients from intervention clinics and control clinics were taking a similar mean number of medications (6.4 vs 6.5) at 6 months, and similar proportions of patients were taking 1 or more potentially inappropriate medications after 6 months. Educating patients and clinicians about deprescribing in primary care did not have an effect on the number of long-term medications or percentage of potentially inappropriate medications for older adults taking 5 or more long-term medications; findings suggest such interventions should target older adults taking relatively more medications. Individuals with dementia or mild cognitive impairment frequently have multiple chronic conditions (defined as ≥2 chronic medical conditions) and take multiple medications, increasing their risk for adverse outcomes. Deprescribing (reducing or stopping medications for which potential harms outweigh potential benefits) may decrease their risk of adverse outcomes. To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment. This pragmatic, patient-centered, 12-month cluster randomized clinical trial was conducted from April 1, 2019, to March 31, 2020, at 18 primary care clinics in a not-for-profit integrated health care delivery system. The study included 3012 adults aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications. An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings. The number of prescribed long-term medications and the percentage of individuals prescribed 1 or more potentially inappropriate medications (PIMs). Analysis was performed on an intention-to-treat basis. This study comprised 1433 individuals (806 women [56.2%]; mean [SD] age, 80.1 [7.2] years) in 9 intervention clinics and 1579 individuals (874 women [55.4%]; mean [SD] age, 79.9 [7.5] years) in 9 control clinics who met the eligibility criteria. At baseline, both groups were prescribed a similar mean (SD) number of long-term medications (7.0 [2.1] in the intervention group and 7.0 [2.2] in the control group), and a similar proportion of individuals in both groups were taking 1 or more PIMs (437 of 1433 individuals [30.5%] in the intervention group and 467 of 1579 individuals [29.6%] in the control group). At 6 months, the adjusted mean number of long-term medications was similar in the intervention and control groups (6.4 [95% CI, 6.3-6.5] vs 6.5 [95% CI, 6.4-6.6]; P = .14). The estimated percentages of patients in the intervention and control groups taking 1 or more PIMs were similar (17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = .08). In preplanned subgroup analyses, adjusted differences between the intervention and control groups were –0.16 (95% CI, –0.34 to 0.01) for individuals prescribed 7 or more long-term medications at baseline (n = 1434) and –0.03 (95% CI, –0.20 to 0.13) for those prescribed 5 to 6 medications (n = 1578) (P = .28 for interaction; P = .19 for subgroup interaction for PIMs). This large-scale educational deprescribing intervention for older adults with cognitive impairment taking 5 or more long-term medications and their primary care clinicians demonstrated small effect sizes and did not significantly reduce the number of long-term medications and PIMs. Such interventions should target older adults taking relatively more medications. ClinicalTrials.gov Identifier: NCT03984396 This cluster randomized clinical trial examines the effectiveness of educating patients and clinicians about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment.
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影响因子：
2.8
作者：
Green, Ariel R.;Reifler, Liza M.;Boyd, Cynthia M.
通讯作者：
Boyd, Cynthia M.
影响因子：
14
作者：
Lin, Pei-Jung;Fillit, Howard M.;Neumann, Peter J.
通讯作者：
Neumann, Peter J.
影响因子：
4.4
作者：
Child, Anne;Clarke, Amy;Maidment, Ian
通讯作者：
Maidment, Ian
DOI：
10.3122/jabfm.2019.03.180335
发表时间：
2019-05-01
影响因子：
2.9
作者：
Green, Ariel R.;Lee, Patricia;Boyd, Cynthia M.
通讯作者：
Boyd, Cynthia M.
影响因子：
5.7
作者：
Davydow, Dimitry S.;Zivin, Kara;Iwashyna, Theodore J.
通讯作者：
Iwashyna, Theodore J.