Workshop, Addressing the limits of medical practice. Wonca 2013

Workshop, Addressing the limits of medical practice. Wonca 2013 DAY: Wednesday June 26, 2013 SESSION: WORKSHOP: 2.15. Ethics and law SESSION TIME: from 10:30 to 12:00 Marc Jamoulle, GP , researcher in Primary care , IRSS-UCL, Belgium Gene Tsoi, Immediate Past President, Hong Kong College of Family Physicians, China Iona Heath, past-president of the Royal College of General Practitioners, United Kingdom Dee Mangin, Director, General Practice Research Group, Associate Professor, Otago university, New Zealand Mohamad Pezeshki, Associate Professor, Department of Community Medicine, Tabriz Medical School, Iran Miguel Pizzanelli Báez, head of the Primary care network, Florida, Uruguay As stated in Wonca dictionary of family Medicine (Bentzen, 2003), quaternary prevention definition is “Action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are scientifically and medically acceptable.” Quaternary prevention, first coined at Wonca world Hong Kong 1995 by M. Jamoulle& M.Roland, describes the protection of patients from diagnostic tests, interventions and treatments that offer no benefit for overall morbidity or mortality for the individual, and may cause physical or psychological harm. The P4 concept pulls together all reflexive moves on the problems resulting from an excess of medical care, such as overscreening, overinvestigation, overprescription, and overtreatment. Since the first workshop in Wonca Basel 2009, the P4 concept has spread throughout the world, and has provoked an intense exchange of ideas. The speakers gathered here from around the world intend to show how front line family physicians could analyze, understand, appropriate and use the P4 concept to examine, analyze and modify their practice. The audience will be stimulated to share their concern about the limits of medicine exchange critical comments on the concept of P4. At the end of the workshop attendees will be able to able to use and apply Quaternary prevention to improve both the health of individual patients and public policy. More on http://www.ph3c.org/P4 rubric Events and conferences about Quaternary Prevention Or http://tinyurl.com/P4-Praga-2013 Speakers Marc Jamoulle : From Illitch to Moynihan , medicine can be dangerous for your health Gene Tsoi ; Doctor-Patient Relationship - sharing of experience with a GP from Hong Kong Iona Heath ; The ethical implications of excessive prevention Dee Mangin : Mutimorbidity, ageing, and Quaternary Prevention Mohammad Zakaria Pezeshki: Clinical Epidemiology and Quaternary Prevention Miguel Pizanelli, Jorge Bernstein & André L. Silva: A South American move; the “Comision de Prevencion Cuaternaria

GeriMedRisk, a telemedicine geriatric pharmacology consultation service to address adverse drug events in long-term care: a stepped-wedge cluster randomized feasibility trial protocol (ISRCTN17219647)

Abstract Background Multimorbidity, polypharmacy, and older age predispose seniors to adverse drug events (ADE). Seniors with an ADE experience greater morbidity, mortality, and health care utilization compared to their younger counterparts. To mitigate and manage ADEs among this vulnerable population, we designed a geriatric pharmacology consultation service connecting clinicians with specialist physicians and pharmacists and will investigate the feasibility and acceptability of this complex intervention in the long-term care setting, prior to conducting a larger efficacy trial. Methods/Design We will conduct a cluster randomized feasibility trial and qualitative analysis of GeriMedRisk among four long-term care homes in the Waterloo-Wellington region from May 1 to December 31, 2017. The primary outcome is the feasibility and acceptability of GeriMedRisk and the stepped-wedge cluster randomized controlled trial design. We hypothesize that GeriMedRisk is a feasible intervention and its potential to decrease falls and drug-related hospital visits can be evaluated with a stepped-wedge cluster randomized controlled trial design. Discussion This mixed methods study will inform a larger efficacy trial of GeriMedRisk’s ability to decrease adverse drug events among seniors in the long-term care setting. Ethics and dissemination The Hamilton Integrated Research Ethics Board granted the approval for this study protocol 2812. We plan to disseminate the results of this study in peer-reviewed journals and also to our partners and stakeholders. Trial registration ISRCTN clinical trials registry, ISRCTN17219647 (March 27, 2017

Recommendations for outcome measurement for deprescribing intervention studies.

Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research

Manifesto de Curitiba: pela Prevenção Quaternária e por uma Medicina sem conflitos de interesse

peer reviewe

Cost-Utility Analysis of Discontinuing Antidepressants in England Primary Care Patients Compared with Long-Term Maintenance: The ANTLER Study

BACKGROUND: Depression is a common mental health condition with considerable negative impact on health and well-being. Although antidepressants are recommended as first-line treatment, there is limited evidence regarding the cost effectiveness of long-term maintenance antidepressants for preventing relapse.OBJECTIVES: Our objective was to calculate the mean incremental costs and quality-adjusted life-years (QALYs) over 12 months of discontinuing long-term antidepressant medication in well patients compared with maintenance, using patient-level trial data.METHODS: We conducted a cost-utility analysis of 478 participants from 150 UK general practices recruited to a randomised, double-blind trial (ANTLER). QALYs were calculated from EQ-5D-5L and 12-Item Short Form survey (SF-12) results, with primary analysis using the EQ-5D-5L value set for England. Resource use was collected from primary care patient electronic medical records and self-completed questionnaires capturing mental-health-related resource use. Costs were calculated by applying standard UK unit costs to resource use. Adjustments were made for baseline variables.RESULTS: Participants randomised to discontinuation had significantly worse utility scores at 3 months (- 0.032; 95% confidence interval [CI] - 0.053 to - 0.011) but no significant difference in QALYs (- 0.011; 95% CI - 0.026 to 0.003) or costs (£3.11; 95% CI - 41.28 to 47.50) at 12 months. The probability that discontinuation was cost effective compared with maintenance was 12.9% at a threshold of £20,000 per QALY gained.CONCLUSIONS: Discontinuation of antidepressants was unlikely to be cost effective compared with maintenance for currently well patients on long-term antidepressants. However, this analysis provides no information on the wider impact of antidepressants. Our findings provide information on the potential impact of discontinuing long-term maintenance antidepressants and facilitate improving guidance for shared patient-clinician decision making.TRIAL REGISTRATION: EudraCT number 2015-004210-26; ISRCTN number ISRCTN15969819.</p

Recommendations for outcome measurement for deprescribing intervention studies

Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/174967/1/jgs17894-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/174967/2/jgs17894.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/174967/3/jgs17894_am.pd