Incidence of and predictors for antiseizure medication gaps in Medicare beneficiaries with epilepsy: a retrospective cohort study.

BACKGROUND For the two-thirds of patients with epilepsy who achieve seizure remission on antiseizure medications (ASMs), patients and clinicians must weigh the pros and cons of long-term ASM treatment. However, little work has evaluated how often ASM discontinuation occurs in practice. We describe the incidence of and predictors for sustained ASM fill gaps to measure discontinuation in individuals potentially eligible for ASM withdrawal. METHODS This was a retrospective cohort of Medicare beneficiaries. We included patients with epilepsy by requiring International Classification of Diseases codes for epilepsy/convulsions plus at least one ASM prescription each year 2014-2016, and no acute visit for epilepsy 2014-2015 (i.e., potentially eligible for ASM discontinuation). The main outcome was the first day of a gap in ASM supply (30, 90, 180, or 360 days with no pills) in 2016-2018. We displayed cumulative incidence functions and identified predictors using Cox regressions. RESULTS Among 21,819 beneficiaries, 5191 (24%) had a 30-day gap, 1753 (8%) had a 90-day gap, 803 (4%) had a 180-day gap, and 381 (2%) had a 360-day gap. Predictors increasing the chance of a 180-day gap included number of unique medications in 2015 (hazard ratio [HR] 1.03 per medication, 95% confidence interval [CI] 1.01-1.05) and epileptologist prescribing physician (≥25% of that physician's visits for epilepsy; HR 2.37, 95% CI 1.39-4.03). Predictors decreasing the chance of a 180-day gap included Medicaid dual eligibility (HR 0.75, 95% CI 0.60-0.95), number of unique ASMs in 2015 (e.g., 2 versus 1: HR 0.37, 95% CI 0.30-0.45), and greater baseline adherence (> 80% versus ≤80% of days in 2015 with ASM pill supply: HR 0.38, 95% CI 0.32-0.44). CONCLUSIONS Sustained ASM gaps were rarer than current guidelines may suggest. Future work should further explore barriers and enablers of ASM discontinuation to understand the optimal discontinuation rate

Deprescribing of Acetylcholinesterase Inhibitors in Older Adult Nursing Home Residents with Severe Dementia

Clinical guidelines and expert opinion suggest that deprescribing or discontinuing AChEIs may be an appropriate strategy to reduce medication burden and risk for adverse events, given the lack of evidence to support their effectiveness in patients with severe dementia. There have been few well-designed studies with adequate sample size that have evaluated the effects of deprescribing AChEIs on outcomes. The findings of this dissertation address a critical gap in the literature by examining the epidemiology and outcomes associated with deprescribing AChEIs. The first study examined the epidemiology of deprescribing AChEIs and found that deprescribing was more likely in older residents who exhibited signs of declining clinical status. By contrast, regional rurality and non-geriatric prescriber specialty was associated with reduced likelihood of deprescribing. In the second study, we evaluated the association of deprescribing AChEIs with behavioral outcomes including depression severity and aggressive behaviors. The overall prevalence of behavioral symptoms in this population was low and deprescribing AChEIs was not found to be associated with a significant change in depressive symptoms or aggressive behaviors. Finally, we examined the downstream impact of deprescribing AChEIs on the use of other medications. Deprescribing AChEIs was associated with a general reduction in the total number of other non-AChEI medications prescribed, including a reduced likelihood of receiving new antipsychotic prescriptions. Deprescribing was not associated with an increased likelihood of discontinuing strong anticholinergic medications that may have originally been prescribed as part of the cholinergic prescribing cascade. The findings presented in this dissertation suggest that deprescribing AChEIs may be a safe approach to reduce medication burden without worsening behavioral symptoms in older nursing home residents with severe dementia. Targeted educational interventions aimed at non-geriatric prescribers in rural nursing facilities may help to improve the dissemination and implementation of deprescribing in clinical practice

Transitioning Focus Group Research to a Videoconferencing Environment: A Descriptive Analysis of Interactivity

The COVID-19 pandemic disrupted face-to-face interactions in healthcare research, with many studies shifting to video-based data collection for qualitative research. This study describes the interactivity achieved in a videoconferencing focus group of seven primary care providers discussing deprescribing opioids and benzodiazepines. Researchers reviewed video footage of a focus group conducted via Zoom and assessed interactivity using Morgan’s framework for focus group communication processes. Two reviewers categorized the type of exchanges as sharing information, comparing experiences, organizing, and conceptualizing the content, as well as validating each other or galvanizing the discussion with “lightning strike” ideas. The conversation dynamics in this focus group included clear examples of interactivity in each of the categories proposed by Morgan (validating, sharing, comparing, organizing, conceptualizing, and lightning strikes) that were observed by two different reviewers with demonstrated high interrater reliability. Conducting focus groups with a skilled moderator using videoconferencing platforms with primary care providers is a viable option that produces sufficient levels of interaction