Validation of the Arabic Version of Medication Regimen Complexity Index Among Older Patients - Validation of the “MRCI-Arabic”

The medication regimen complexity index is widely used in clinical practice and many studies, to assess the complexity of medication regimens. The goal of this study is to validate the medication regimen complexity index-Arabic (MRCI-Arabic) version among older patients. Methods: This methodologic study was conducted in older patients (≥ 65 years old) who were native Arabic speakers at a community pharmacy located in Istanbul, Turkey. After the translation and cultural adaptation process finished, medication regimens of 30 patients were evaluated for test-retest reliability three weeks apart by the rater who was a native Arabic speaker. The inter-rater correlation was calculated in study population (n =100). The link between the number of medications and the score of medication regimen complexity was used to assess convergent validity. The difference in the score of pharmaceutical regimen complexity in stratified age groups was used to examine discriminant validity. Results: The inter-rater and test-retest reliability of the MRCI-Arabic total scale and its subsection were extremely high (Spearman’s rho ranged from 0.996 to 1; p <0.001). There was a strong and positive correlation between the total MRCI-Arabic score and the number of medications (r = 0.830; p < 0.001), the number of chronic diseases (r = 0.641; p < 0.001). Conclusion: The Arabic validation of the MRCI is a validated tool that can be used by native Arabic-speaking healthcare professionals to determine the complexity of their patients’ medication regimens

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 the spread and scale of PatientToc™ from primary care to community pharmacy practice for the collection of patient-reported outcomes: A study protocol

Background Medication non-adherence is a problem of critical importance, affecting approximately 50% of all persons taking at least one regularly scheduled prescription medication and costing the United States more than $100 billion annually. Traditional data sources for identifying and resolving medication non-adherence in community pharmacies include prescription fill histories. However, medication possession does not necessarily mean patients are taking their medications as prescribed. Patient-reported outcomes (PROs), measuring adherence challenges pertaining to both remembering and intention to take medication, offer a rich data source for pharmacists and prescribers to use to resolve medication non-adherence. PatientToc™ is a PROs collection software developed to facilitate collection of PROs data from low-literacy and non-English speaking patients in Los Angeles. Objectives This study will evaluate the spread and scale of PatientToc™ from primary care to community pharmacies for the collection and use of PROs data pertaining to medication adherence. Methods The following implementation and evaluation steps will be conducted: 1) a pre-implementation developmental formative evaluation to determine community pharmacy workflow and current practices for identifying and resolving medication non-adherence, potential barriers and facilitators to PatientToc™ implementation, and to create a draft implementation toolkit, 2) two plan-do-study-act cycles to refine an implementation toolkit for spreading and scaling implementation of PatientToc™ in community pharmacies, and 3) a comprehensive, theory-driven evaluation of the quality of care, implementation, and patient health outcomes of spreading and scaling PatientToc™ to community pharmacies. Expected impact This research will inform long-term collection and use of PROs data pertaining to medication adherence in community pharmacies

Constrained Differentially Private Federated Learning for Low-bandwidth Devices

Federated learning becomes a prominent approach when different entities want to learn collaboratively a common model without sharing their training data. However, Federated learning has two main drawbacks. First, it is quite bandwidth inefficient as it involves a lot of message exchanges between the aggregating server and the participating entities. This bandwidth and corresponding processing costs could be prohibitive if the participating entities are, for example, mobile devices. Furthermore, although federated learning improves privacy by not sharing data, recent attacks have shown that it still leaks information about the training data. This paper presents a novel privacy-preserving federated learning scheme. The proposed scheme provides theoretical privacy guarantees, as it is based on Differential Privacy. Furthermore, it optimizes the model accuracy by constraining the model learning phase on few selected weights. Finally, as shown experimentally, it reduces the upstream and downstream bandwidth by up to 99.9% compared to standard federated learning, making it practical for mobile systems.Comment: arXiv admin note: text overlap with arXiv:2011.0557

Privacy-Preserving and Bandwidth-Efficient Federated Learning: An Application to In-Hospital Mortality Prediction

International audienceMachine Learning, and in particular Federated Machine Learning, opens new perspectives in terms of medical research and patient care. Although Federated Machine Learning improves over centralized Machine Learning in terms of privacy, it does not provide provable privacy guarantees. Furthermore, Federated Machine Learning is quite expensive in term of bandwidth consumption as it requires participant nodes to regularly exchange large updates. This paper proposes a bandwidth-efficient privacy-preserving Federated Learning that provides theoretical privacy guarantees based on Differential Privacy. We experimentally evaluate our proposal for in-hospital mortality prediction using a real dataset, containing Electronic Health Records of about one million patients. Our results suggest that strong and provable patient-level privacy can be enforced at the expense of only a moderate loss of prediction accuracy

FUNCTIONAL AND COGNITIVE STATUS AND MEDICATION COMPLEXITY IN OLDER ADULTS: THE HEALTH AND RETIREMENT STUDY

Introduction: Older adults have high prevalence of chronic illnesses that lead to have complex medication regimens. They are also more likely to have cognitive and functional impairments. Both cognitive/functional impairments and medication regimen complexity increase the risk of medication non-adherence. The objective of this study is to evaluate the association between prescription medication regimen complexity and cognitive/functional status at baseline and after two years, and to assess how changes in cognitive/functional status are associated with changes in medication regimen complexity. Methods: This study used nationally representative sample of community-dwelling older adults from the Health and Retirement Study, followed over a two-year period. The exposures examined were cognitive status, and two types of functional status (Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The association between cognitive/functional status and medication regimen complexity was examined at baseline and after two years. Similar models were used to examine the relationship between cognitive/functional impairment and sub-components of complexity, and to assess how changes in cognitive/functional impairment were associated with changes in medication complexity over two years. Results:Impairment in ADLs were associated with higher medication complexity at baseline (p=0.0029) and after two years (p=0.0243). Impairments in IADLs were associated with higher regimen complexity at baseline only (p=0.0130). Stratifying by depression status, IADL impairment was found to predict higher complexity at both time points, but only in participants without depression. Cognitive impairment was associated with lower medication regimen complexity at baseline (p Conclusion: ADL impairment was strongly associated with higher medication complexity. IADL impairment showed some association with higher medication complexity, but this relationship may vary according to depression status and requires further investigation. Recognition of these impairments may offer health care providers the opportunity to intervene by re-assessing medication regimens for patients with functional impairments. Cognitive impairment was associated with lower medication complexity. Changes in cognitive or functional were not associated with changes in complexity. Further study is needed to investigate this relationship over a longer period of time

Examining the association of medication complexity with health-related quality of life in older adults receiving community-based long term services and supports

While the complexity of a medication regimen is a concern for all individuals, it is of significant concern for community-dwelling older adults who often require multiple medications to treat chronic health problems. Health related quality of life (HRQoL) has been identified as a key quality outcome measure when assessing care of older adults, particularly those with long-term care needs. Although the use of multiple medications has been widely explored in the literature, there is a paucity of data regarding the combination of several medication-related factors (number of active medications, therapeutic drug class, and medication regimen complexity) and HRQoL in older adults. Wilson and Cleary\u27s health-related quality of life conceptual model was the theoretical framework used to guide this study. This secondary analysis examined the relationship among the number of active medications, the number of therapeutic drug classes, and medication regimen complexity and HRQoL in community-dwelling older adults (68% Hispanic, 75% female) who were recent recipients of home and community-based services (H&CBS). The subjects in this study (N =123) were enrolled in a large, multi-site study (N=470) (R01-AG025524, PI, M. Naylor). Medication-related data were obtained from medical charts, counted to include the active number of medications as all prescription and over the counter drugs (mean =9.3), and a therapeutic drug class tool (mean =4.9) measured the number of distinct therapeutic drug classes included in a medication regimen. Medication regimen complexity (mean = 20.6) was measured using the Medication Regimen Complexity Index (MRCI). The Medical Outcomes Study Short Form (MOS SF-12 v2) physical (PCS) and mental component scores (MCS) measured HRQoL. After controlling for age, gender, education, race, ethnicity, marital status and cognitive status, it was determined that the number of active medications (beta coefficient -.497, p=.012) was a key predictor of physical health-related quality of life, while therapeutic drug class and medication regimen complexity were not associated with either physical or mental health-related quality of life. The number of medications impacts on physical health-related quality of life but the directionality of that relationship is not clear; there were no significant effects on mental health-related-related quality of life and medication-related variables. Keywords: Older adults, active medications, therapeutic drug class, medication regimen complexity, community-based long term services and supports

O uso de psicotrópicos e estupefacientes numa população específica - complexidade terapêutica

Psicotrópicos e estupefacientes são medicamentos com forte ação sobre o Sistema Nervoso Central e que desencadeiam alterações a nível da perceção e estímulo. Têm um papel importante a nível medicinal pelas suas propriedades terapêuticas. Devido aos seus efeitos nocivos, como a habituação e a dependência são por vezes utilizados de forma ilegal o que determinou que fossem sujeitos a medidas de controlo especial. A habituação carateriza-se pelo hábito progressivo do organismo ao medicamento que resulta numa diminuição do efeito do mesmo e aumento da dose. A dependência pela necessidade de tomar o medicamento e geralmente em doses consecutivamente maiores, devido à dependência dos efeitos físicos e psíquicos que estes produzem. A complexidade terapêutica pode ser determinada com recurso ao Índice de Complexidade da Farmacoterapia que tem por base a forma farmacêutica, a frequência de dose e as instruções adicionais de administração. Foi realizado um estudo observacional, descritivo, numa farmácia comunitária do Norte do país, que teve como objetivo principal quantificar a complexidade terapêutica utilizando o Índice de Complexidade da Farmacoterapia em prescrições de psicotrópicos e estupefacientes sujeitos a controlo especial, com a finalidade de verificar se houve um aumento da complexidade terapêutica neste grupo específico de medicamentos dispensados entre 2010 e 2017. Obteve-se uma diminuição da complexidade terapêutica em cerca de 1,17 pontos no período analisado. O metilfenidato foi o medicamento mais prescrito, representando 44,4% das prescrições o que pode ter contribuído para o elevado número de doentes do género masculino e igualmente para um maior número de doentes observado nas faixas etárias mais jovens. A Secção A, forma de administração, e a Secção B, frequência de dose, contribuíram para a diminuição do ICFT, sendo mais pronunciada na Secção B (r=0,972). A principal limitação desta investigação foi na seleção da amostra e no cálculo da complexidade terapêutica pois a análise deveria ter sido efetuada englobando a totalidade do regime terapêutico de cada doente e não só os medicamentos sujeitos a controlo especial

Impact des activités du pharmacien sur la qualité de la pharmacothérapie des patients ayant des besoins complexes suivis en GMF-UMF

Récemment, des rehaussements en ressources humaines professionnelles, dont les pharmaciens, ont eu lieu au sein de plusieurs Groupes et Unités de Médecine de Famille (GMF-UMF) du Québec. Notre objectif est de mesurer l'impact des interventions des pharmaciens sur la pharmacothérapie des patients ayant des besoins complexes suivis dans les GMF-UMF. Les problèmes liés à la pharmacothérapie (PRP), la complexité du régime médicamenteux et l’adhésion au traitement chez les patients ayant des besoins complexes référés par leur médecin, ont été comparés avant et après les interventions du pharmacien dans quatre GMF-UMF à Québec. Les PRP identifiés ont été regroupés et décrits en utilisant la classification de Strand. La complexité du régime médicamenteux a été mesurée en utilisant l'indice de complexité du régime médicamenteux (MRCI) tandis qu’on a mesuré l’adhésion à l’aide de la proportion de jours couverts (PDC) en se basant sur l'information du bilan comparatif des médicaments (BCM). Les moyennes des MRCI et des PDC, avant et après les interventions des pharmaciens, ont été comparées par un test-t sur échantillons appariés. Dans cette étude, 92 patients ont été référés aux pharmaciens, dont 64 ont été sélectionnés suivant les critères d’inclusion, parmi lesquels, 56 patients ayant 2 BCM ont été inclus dans l’analyse. L’échantillon se composait majoritairement de femmes âgées ayant de multiples comorbidités, une polypharmacie et un régime médicamenteux complexe. Le pharmacien détectait en moyenne 7,2 PRP par patient. Ses interventions ont mené à une diminution de la complexité du régime médicamenteux (différence des moyennes (DM) de 5,44 au MRCI) et à une augmentation de l’adhésion aux traitements (DM de 5,6 % pour la PDC). Les pharmaciens GMF-UMF ont pu détecter et résoudre les PPR, diminuer la complexité du régime médicamenteux et la non-adhésion aux traitements chez les patients ayant des besoins complexes dans les cliniques de soins de première ligne.Recently, improvements in professional human resources, including pharmacists, took place within several Family Medicine Groups and Units (FMG-FMU) in Quebec. Our objective, is to measure the impact of pharmacist’ interventions on the pharmacotherapy for patients with complex needs monitored in FMG-FMU in Quebec City. Drug related problems (DRPs), medication regimen complexity and adherence to treatment in patients with complex needs referred by their physician, have been compared before and after the pharmacist' interventions in four FMG-FMU in Quebec City. Identified DRP were grouped and described using Strand classification. The medication regimen complexity was calculated using the medication regimen complexity index (MRCI) while adherence was measured using the proportion of days covered (PDC) based on information of medication reconciliation (MedRec). The MRCI and PDC means, before and after pharmacists’ interventions, were compared with a paired sample t-test. In this study, 92 patients were referred to pharmacists, of whom 64 were selected according to the inclusion criteria, of which 56 patients with 2 MedRec were included in the analysis. The sample consisted mainly of elderly women with multiple comorbidities and suffering from poly-pharmacy and medication regimen complexity. An average of 7.2 PRP / patient was found as well as a decrease in the medication regimen complexity of 5.44 and an increase in adherence to treatment of 5.6%. The FMG-FMU pharmacists could detect and resolve DRPs, decrease medication regimen complexity and non-adherence to treatment in patients with complex needs in primary care clinics