Influence of medication risks and benefits on treatment preferences in older patients with multimorbidity

Multimorbidity is associated with use of multiple medicines, increased risk of adverse events and treatment conflicts. This study aimed to examine how older patients with multimorbidity and clinicians balance the benefits and harms associated with a medication and in the presence of competing health outcomes. Interviews were conducted with 15 participants aged ≥65 years with 2 or more chronic conditions. Three clinical scenarios were presented to understand patient preference to take a medicine according to i) degree of benefit, ii) type of adverse event and impact on daily living and iii) influence of comorbid conditions as competing health outcomes. Semi-structured interviews were also conducted with participants (n=15) and clinicians (n=5) to understand patient preferences and treatment decisions, in the setting of multimorbidity. The median age of participants was 79 years, 55% had 5 or more conditions and 47% took 8 or more medicines daily. When the level of benefit of the medicine ranged from 14% to 70%, 80% of participants chose to take the medicine, but when adverse effects were present, this was reduced to 0-33% depending upon impact on daily activities. In the presence of competing health outcomes, 13%-26% of patients chose to take the medicine. Two-thirds of patients reported that their doctor respects and considers their preferences and discussed medication benefits and harms. Interviews with clinicians showed that their overall approach to treatment decision-making for older individuals with multimorbidity was based upon 2 main factors, the patients' prognosis and their preferences. The degree of benefit gained was not the driver of patients' preference to take a medicine; rather, this decision was influenced by type and severity of adverse effects. Inclusion of patient preferences in the setting of risks and benefits of medicines with consideration and prioritization of competing health outcomes may result in improved health outcomes for people with multimorbidity.Gillian E Caughey, Kirsty Tait, Agnes I Vitry, Sepehr Shaki

Heart failure after conventional metal-on-metal hip replacements: a retrospective cohort study

Background and purpose - It is unclear whether metal particles and ions produced by mechanical wear and corrosion of hip prostheses with metal-on-metal (MoM) bearings have systemic adverse effects on health. We compared the risk of heart failure in patients with conventional MoM total hip arthroplasty (THA) and in those with metal-on-polyethylene (MoP) THA. Patients and methods - We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs health claims database on patients who received conventional THA for osteoarthritis between 2004 and 2012. The MoM THAs were classified into groups: Articular Surface Replacement (ASR) XL Acetabular System, other large-head (LH) (> 32 mm) MoM, and small-head (SH) (≤ 32 mm) MoM. The primary outcome was hospitalization for heart failure after THA. Results - 4,019 patients with no history of heart failure were included (56% women). Men with an ASR XL THA had a higher rate of hospitalization for heart failure than men with MoP THA (hazard ratio (HR) = 3.2, 95% CI: 1.6-6.5). No statistically significant difference in the rate of heart failure was found with the other LH MoM or SH MoM compared to MoP in men. There was no statistically significant difference in heart failure rate between exposure groups in women. Interpretation - An association between ASR XL and hospitalization for heart failure was found in men. While causality between ASR XL and heart failure could not be established in this study, it highlights an urgent need for further studies to investigate the possibility of systemic effects associated with MoM THA.Marianne H Gillam, Nicole L Pratt, Maria C S Inacio, Elizabeth E Roughead, Sepehr Shakib, Stephen J Nicholls & Stephen E Grave

Guideline compliance in chronic heart failure patients with multiple comorbid diseases: evaluation of an individualised multidisciplinary model of care

OBJECTIVE: To assess the impact of individualised, reconciled evidence-based recommendations (IRERs) and multidisciplinary care in patients with chronic heart failure (CHF) on clinical guideline compliance for CHF and common comorbid conditions. DESIGN AND SETTING: A retrospective hospital clinical audit conducted between 1st July 2006 and February 2011. PARTICIPANTS: A total of 255 patients with a diagnosis of CHF who attended the Multidisciplinary Ambulatory Consulting Services (MACS) clinics, at the Royal Adelaide Hospital, were included. MAIN OUTCOME MEASURES: Compliance with Australian clinical guideline recommendations for CHF, atrial fibrillation, diabetes mellitus and ischaemic heart disease. RESULTS: Study participants had a median of eight medical conditions (IQR 6-10) and were on an average of 10 (±4) unique medications. Compliance with clinical guideline recommendations for pharmacological therapy for CHF, comorbid atrial fibrillation, diabetes or ischaemic heart disease was high, ranging from 86% for lipid lowering therapy to 98% anti-platelet agents. For all conditions, compliance with lifestyle recommendations was lower than pharmacological therapy, ranging from no podiatry reviews for CHF patients with comorbid diabetes to 75% for heart failure education. Concordance with many guideline recommendations was significantly associated if the patient had IRERs determined, a greater number of recommendations, more clinic visits or if patients participated in a heart failure program. CONCLUSIONS: Despite the high number of comorbid conditions and resulting complexity of the management, high compliance to clinical guideline recommendations was associated with IRER determination in older patients with CHF. Importantly these recommendations need to be communicated to the patient's general practitioner, regularly monitored and adjusted at clinic visits.Tam H. Ho, Gillian E. Caughey, Sepehr Shaki

Analysis of proteomic profiles and functional properties of human peripheral blood myeloid dendritic cells, monocyte-derived dendritic cells and the dendritic cell-like KG-1 cells reveals distinct characteristics

Important proteomic and functional differences between peripheral blood myeloid dendritic cells, monocyte-derived dendritic cells (moDC) and KG-1 cells have been identified

Depression diagnosis and treatment amongst multimorbid patients: a thematic analysis

BACKGROUND: We explored experiences of depression diagnosis and treatment amongst multimorbid patients referred to a metropolitan multidisciplinary outpatient clinic to identify commonalities across this patient group. METHODS: Patients with two or more chronic conditions and a diagnosis of depression participated in semi-structured interviews that were digitally recorded and transcribed. Thematic analysis was performed on the transcriptions. RESULTS: Multimorbid patients attributed depressive symptoms to the loss of 'normal' roles and functionality and struggled to reconcile the depression diagnosis with their sense of identity. Beliefs about themselves and depression affected their receptivity to diagnosis and intervention strategies. These included prescribed interventions, such as psychotherapy or pharmacotherapy, and patient-developed strategies. CONCLUSIONS: Functional and social role losses present a clear context in which GPs should raise the subject of mood, with the situational attribution of depression suggesting that psychotherapy, which is rarely offered, should be prioritised in these circumstances.Melinda N Stanners, Christopher A Barton, Sepehr Shakib and Helen R Winefiel

A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments

Problem: Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design: Before and after study. Background and setting: Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement: Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change: Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as "gatekeepers." Effects of change: Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). Lessons learnt: Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.Taryn Bessen, Robyn Clark, Sepehr Shakib, Geoffrey Hughe

The prevalence of depression amongst outpatients with multimorbidity

Objectives: Depression may be under-diagnosed and under-treated amongst older adults with multiple chronic illnesses. The current study explores the prevalence of depression diagnosis and Geriatric Depression Scale (GDS) symptoms amongst older multimorbid outpatients, and agreement between GDS scores and doctor-diagnosed depression. Method: Deidentified data from the files of 452 patients aged over 64, with chronic conditions present in two or more organ domains, were extracted from the clinical database of a tertiary referral hospital multidisciplinary outpatient clinic in South Australia between 2005 and 2011. Frequency calculations determined the prevalence of depression diagnosis and GDS categories. Logistic regression, cross-tabulation, kappa and ROC graphs explored relationships between variables. Results: A depression diagnosis had been recorded for 71 (15.7%) patients. Using the recommended cut-off scores for the GDS, 225 (49.8%) patients met criteria for mild-severe depressive symptoms, and 96 (21.3%) met criteria for moderate-severe symptoms. Poor agreement was found between doctor diagnosis of depression and a positive screen for depression using a GDS cut-off score of either 5, k = 0.112 (p = 0.001), or 9, k = 0.189 (p < 0.001), although logistic regression found an association between severity of depression and depression diagnosis, OR = 1.15, p < 0.001 (CI = 1.08 - 1.22). Con-clusion: A much higher proportion of patients with multimorbidities reported threshold level depression symptoms than had a recorded diagnosis of depression, suggesting that although likelihood of diagnosis increases with symptom severity, depression often goes undetected in this population. Depressions’ negative impact on prognosis calls for further investigation of the barriers to screening and diagnosis of depression in multimorbid patients.Melinda Stanners, Christopher Barton, Sepehr Shakib, Helen Winefiel

What factors are important for deprescribing in Australian long-term care facilities? Perspectives of residents and health professionals

Polypharmacy and multimorbidity are common in long-term care facilities (LTCFs). Reducing polypharmacy may reduce adverse events and maintain quality of life. Deprescribing refers to reducing medications after consideration of therapeutic goals, benefits and risks, and medical ethics. The objective was to use nominal group technique (NGT) to generate then rank factors that general medical practitioners (GPs), nurses, pharmacists and residents or their representatives perceive are most important when deciding whether or not to deprescribe medications.Qualitative research using NGT.Participants were invited if they worked with, or resided in LTCFs across metropolitan and regional South Australia.11 residents/representatives, 19 GPs, 12 nurses and 14 pharmacists participated across six separate groups.Individual groups of GPs, nurses, pharmacists and residents/representatives were convened. Using NGT each group ranked factors perceived to be most important when deciding whether or not to deprescribe. Then, using NGT, the prioritised factors from individual groups were discussed and prioritised by a multidisciplinary metropolitan and regional group comprised of resident representatives, GPs, nurses and pharmacists.No two groups had the same priorities. GPs ranked 'evidence for deprescribing' and 'communication with family/resident' as most important factors. Nurses ranked 'GP receptivity to deprescribing' and 'nurses ability to advocate for residents' as most important. Pharmacists ranked 'clinical appropriateness of therapy' and 'identifying residents' goals of care' as most important. Residents ranked 'wellbeing of the resident' and 'continuity of nursing staff' as most important. The multidisciplinary groups ranked 'adequacy of medical and medication history' and 'identifying residents' goals of care' as most important.While each group prioritised different factors, common and contrasting factors emerged. Future deprescribing interventions need to consider the similarities and differences within the range of factors prioritised by residents and health professionals.Justin P Turner, Susan Edwards, Melinda Stanners, Sepehr Shakib, J Simon Bel