24 research outputs found
Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review
Background: Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a
common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal
from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects
of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing
as an effective strategy for improving medication adherence amongst older, community dwelling adults.
Methods: A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers
were searched between May and December 2017. Results were double screened in accordance with pre-defined
inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling
populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection
instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was
analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was
performed in accordance with the PRISMA reporting statement.
Results: A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an
outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13
countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners
(GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with
improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was
reported as a secondary outcome in all but one study.
Conclusions: There is insufficient evidence to show that deprescribing improves medication adherence. Only 13
studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly
susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors
including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend
further study into the efficacy and outcomes of medicines management interventions. A consensus on priority
outcome measurements for prescribed medications is indicated
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Comparing marginal structural models to standard methods for estimating treatment effects of antihypertensive combination therapy
<p>Abstract</p> <p>Background</p> <p>Due to time-dependent confounding by blood pressure and differential loss to follow-up, it is difficult to estimate the effectiveness of aggressive versus conventional antihypertensive combination therapies in non-randomized comparisons.</p> <p>Methods</p> <p>We utilized data from 22,576 hypertensive coronary artery disease patients, prospectively enrolled in the INternational VErapamil-Trandolapril STudy (INVEST). Our post-hoc analyses did not consider the randomized treatment strategies, but instead defined exposure time-dependently as aggressive treatment (≥3 concomitantly used antihypertensive medications) versus conventional treatment (≤2 concomitantly used antihypertensive medications). Study outcome was defined as time to first serious cardiovascular event (non-fatal myocardial infarction, non-fatal stroke, or all-cause death). We compared hazard ratio (HR) estimates for aggressive vs. conventional treatment from a Marginal Structural Cox Model (MSCM) to estimates from a standard Cox model. Both models included exposure to antihypertensive treatment at each follow-up visit, demographics, and baseline cardiovascular risk factors, including blood pressure. The MSCM further adjusted for systolic blood pressure at each follow-up visit, through inverse probability of treatment weights.</p> <p>Results</p> <p>2,269 (10.1%) patients experienced a cardiovascular event over a total follow-up of 60,939 person-years. The HR for aggressive treatment estimated by the standard Cox model was 0.96 (95% confidence interval 0.87-1.07). The equivalent MSCM, which was able to account for changes in systolic blood pressure during follow-up, estimated a HR of 0.81 (95% CI 0.71-0.92).</p> <p>Conclusions</p> <p>Using a MSCM, aggressive treatment was associated with a lower risk for serious cardiovascular outcomes compared to conventional treatment. In contrast, a standard Cox model estimated similar risks for aggressive and conventional treatments.</p> <p>Trial registration</p> <p>Clinicaltrials.gov Identifier: NCT00133692</p