Physician factors associated with polypharmacy and potentially inappropriate medication use among family medicine residency practices

Background: Despite accumulating evidence about the impact of polypharmacy on public health, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physician prescribing behavior. Methods: We conducted a physician survey at five family medicine residency practices and a linked health record review of their patients 65 years or older. The determinants of physicians’ mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model. Results: A total of 61 physicians (38 residents and 23 fellows/faculty) completed the survey and 2,103 visits by 932 patients seen by these physicians were analyzed. The mean prescription and PIM numbers per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider number of medications (p=0.007) and benefit/risk information for deprescribing (p=0.017) in prescribing decisions. Low PIM prescribers also considered these two factors and the Beers list (p=0.05). Physicians’ sex, length of experience, and perceived confidence were not associated with prescribing patterns. Public Health Significance: Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers list, were associated with less polypharmacy and PIMs use. Our results warrant further research and education to address prescription-related problems among older patients, especially with a focus on enhancing deprescribing to improve patient outcomes while reducing inappropriate healthcare utilization and costs

Deprescribing as an Opportunity to Facilitate Patient-Centered Care: A Qualitative Study of General Practitioners and Pharmacists in Japan

Deprescribing has recently been applied to address polypharmacy, particularly among older adults. However, the characteristics of deprescribing that are likely to improve health outcomes have not been well studied. This study explored the experiences and perspectives of general practitioners and pharmacists with regard to deprescribing in older adults with multimorbidity. A qualitative study was conducted involving eight semi-structured focus group interviews with 35 physicians and pharmacists from hospitals, clinics, and community pharmacies. Thematic analysis was applied to identify themes using the theory of planned behavior as a guide. The results illustrated a metacognitive process, as well as influencing factors, through which healthcare providers commit to shared decision making for deprescribing. Healthcare providers acted on the basis of their attitudes and beliefs on deprescribing, the influence of subjective norms, and perceived behavioral control for deprescribing. These processes are influenced by factors such as drug class, prescribers, patients, deprescribing experience, and environment/education. Healthcare providers’ attitudes, beliefs, and behavioral control (along with deprescribing strategies) evolve in a dynamic interplay with experience, environment, and education. Our results can serve as a foundation for the development of effective patient-centered deprescribing to improve the safety of pharmaceutical care for older adults

Development of a questionnaire to measure primary care physicians' scope of practice

application/pdfBackground: Despite an increase in research devoted to primary care attributes, the patient benefits and educational aspects of broad scope practice of primary care physicians (PCPs) have not been well studied, due to a lack of validated measurement in each country. The objective of this study was to develop and validate the Scope of Practice Inventory (SPI) to measure physicians' scope of practice within the Japanese primary care setting. Methods: The questionnaire was developed in seven phases: 1) item generation, 2) consensus method for necessity of each item, 3) Delphi process for the importance of each item, 4) pilot tests to limit the number of items, 5) preliminary cross-sectional study to examine factor structure and to validate the construct validity, 6) evaluation of internal consistency and intra-class reliability, and 7) evaluation of external validity. To confirm the interpretability of the SPI, the determinants of the SPI using a generalized linear model were evaluated. Results: Among 359 items generated by a focus group, 180 reached a defined consensus on face and content validity after the Delphi process. After deletion of items with Kappa values less than 0.6, 120 items were selected for the preliminary study. The principle component analysis using responses from 451 PCPs eliminated 52 items. The final 68-point SPI had three subdomains: Inpatient care, 25 items; Urgent care and minor procedures, 27 items; and Ambulatory care, 16 items. Internal consistency and test-retest reliability for total SPI and each subdomain revealed acceptable reliability. Male sex, less years since graduation, working in a hospital, sub-urban or rural setting, having remote experience, and having board certification as a PCP were positively associated with higher SPI. Conclusions: We developed a self-administered 68-point scale, the SPI, which had satisfactory validity and reliability. Primary care quality and educational research using SPI are expected to contribute to comprehensive and efficient health care systems in the future.本文 / Department of Family Medicine, Mie University School of Medicine; Graduate School of Public Health, University of Pittsburgh9

Development of a questionnaire to measure primary care physicians' scope of practice

application/pdf内容の要旨・審査結果の要旨 / 三重大学大学院医学系研究科 生命医科学専攻 臨床医学系講座 家庭医療学分

Additional file 2: of Development of a questionnaire to measure primary care physicians’ scope of practice

The Scope of Practice Inventory (Japanese version). (DOC 110 kb

Treatment strategy for insomnia disorder: Japanese expert consensus

PurposeThere is a lack of evidence regarding answers for clinical questions about treating insomnia disorder. This study aimed to answer the following clinical questions: (1) how to use each hypnotic and non-pharmacological treatment differently depending on clinical situations and (2) how to reduce or stop benzodiazepine hypnotics using alternative pharmacological and non-pharmacological treatments.MethodsExperts were asked to evaluate treatment choices based on 10 clinical questions about insomnia disorder using a nine-point Likert scale (1 = “disagree” to 9 = “agree”). The responses of 196 experts were collected, and the answers were categorized into first-, second-, and third-line recommendations.ResultsThe primary pharmacological treatment, lemborexant (7.3 ± 2.0), was categorized as a first-line recommendation for sleep initiation insomnia, and lemborexant (7.3 ± 1.8) and suvorexant (6.8 ± 1.8) were categorized as the first-line recommendations for sleep maintenance insomnia. Regarding non-pharmacological treatments for primary treatment, sleep hygiene education was categorized as the first-line recommendation for both sleep initiation (8.4 ± 1.1) and maintenance insomnia (8.1 ± 1.5), while multicomponent cognitive behavioral therapy for insomnia was categorized as the second-line treatment for both sleep initiation (5.6 ± 2.3) and maintenance insomnia (5.7 ± 2.4). When reducing or discontinuing benzodiazepine hypnotics by switching to other medications, lemborexant (7.5 ± 1.8) and suvorexant (6.9 ± 1.9) were categorized as first-line recommendations.ConclusionExpert consensus indicates that orexin receptor antagonists and sleep hygiene education are recommended as first-line treatments in most clinical situations to treat insomnia disorder

Management of unspecified anxiety disorder: Expert consensus

Abstract Aims Treatment guidelines with respect to unspecified anxiety disorder have not been published. The aim of this study was to develop a consensus among field experts on the management of unspecified anxiety disorder. Methods Experts were asked to evaluate treatment choices based on eight clinical questions concerning unspecified anxiety disorder using a nine‐point Likert scale (1 = “disagree” to 9 = “agree”). According to the responses from 119 experts, the choices were categorized into first‐, second‐, and third‐line recommendations. Results Benzodiazepine anxiolytic use was not categorized as a first‐line recommendation for the primary treatment of unspecified anxiety disorder, whereas multiple nonpharmacological treatment strategies, including coping strategies (7.9 ± 1.4), psychoeducation for anxiety (7.9 ± 1.4), lifestyle changes (7.8 ± 1.5), and relaxation techniques (7.4 ± 1.8), were categorized as first‐line recommendations. Various treatment strategies were categorized as first‐line recommendations when a benzodiazepine anxiolytic drug did not improve anxiety symptoms, that is, differential diagnosis (8.2 ± 1.4), psychoeducation for anxiety (8.0 ± 1.5), coping strategies (7.8 ± 1.5), lifestyle changes (7.8 ± 1.5), relaxation techniques (7.2 ± 1.9), and switching to selective serotonin reuptake inhibitors (SSRIs) (7.0 ± 1.8). These strategies were also highly endorsed when tapering the dosage of or discontinuing benzodiazepine anxiolytic drugs. There was no first‐line recommendation regarding excusable reasons for continuing benzodiazepine anxiolytics. Conclusions The field experts recommend that benzodiazepine anxiolytics should not be used as a first‐line option for patients with unspecified anxiety disorder. Instead, several nonpharmacological interventions and switching to SSRIs were endorsed for the primary treatment of unspecified anxiety disorder and as alternatives to benzodiazepine anxiolytics