Community-dwelling older people’s attitudes towards deprescribing in Canada

Background: While there is evidence that supervised withdrawal of inappropriate medications might be beneficial for individuals with polypharmacy, little is known about their attitudes towards deprescribing. Objective: This study aimed to describe the situation among older community-dwelling Canadians. Methods: A self-administered survey was adapted from the Patients’ Attitudes Towards Deprescribing questionnaire and distributed to 10 community pharmacies and 2 community centers. The participants rated their agreement on statements about polypharmacy/deprescribing on a 5-point, Likert-type scale. Correlations between the desire to have medications deprescribed and survey items were evaluated using Spearman’s Rho and Goodman and Kurska’s gamma rank correlations. Results: From the 129 participants, 63% were women [median age: 76 (IQR:71–80); median number medication: 6 (IQR: 3–8)]. A proportion of 50.8% (95%CI: 41.6%–60.0%) expressed the desire to reduce their number of medications. This desire was strongly correlated with the individuals’ feeling of taking a large number of medications and moderately correlated with the belief that some of the medications were no longer needed or that they were experiencing side effects. Conclusions: The results show that older individuals in the community are eager to undertake deprescribing, especially if they have a large number of medications, are experiencing side effects or feel some medications are no longer necessary

Pharmacy record registration of acetyl salicylic acid (ASA) prescriptions in Quebec

Purpose: To determine the extent of which acetyl salicylic acid (ASA) use is included in patients' pharmacy records. Methods: During an in-home interview, people aged ≥ 65 years were asked to report all of the medications they had used at least once, including over-the-counter drugs, during the preceding month. Researchers recorded information on the drug name, reason for its use, and whether a physician prescribed it. From the pharmacy records, the drug names, prescription fill dates, quantities supplied, and the numbers of days' supply were recorded. The level of agreement for ASA use across data sources was assessed using proportions of agreement and kappa coefficients. Results: Of 193 individuals interviewed, 86 reported the use of ASA, including 76 ASA users (88.4%) who said it was prescribed by a physician. Pharmacy medication records indicated that there were 74 users of ASA. The proportion of agreement for ASA use was 93.8%, and kappa coefficient was 0.87 (95% confidence interval: 0.80-0.94). The sensitivity, specificity, and positive predictive value of the pharmacy data were all high. Conclusions: A large proportion of ASA use is documented in pharmacy records in Quebec. Thus, the information regarding ASA use in pharmacy records is reliable. This result may not be reproducible in other settings where pharmaceutical reimbursement rules are different

Anticoagulant use in patients with cancer associated venous thromboembolism : a retrospective cohort study

Introduction: Long term anticoagulant therapy is recommended for treatment and secondary prevention of venous thromboembolism in cancer patients. We assessed outpatient anticoagulants [warfarin, low molecular weight heparins (LMWHs), fondaparinux and unfractionated heparin (UFH)] use in adult, cancer patients, 20 years of age or older, who incurred a venous thromboembolism (primary or secondary in-hospital diagnosis) in Quebec, Canada between 2007 and 2009. Materials and methods: Data were obtained from the Quebec Health Insurance Agency. Patients with an in-hospital cancer diagnosis between April 2007 and June 2009 and an in-hospital venous thromboembolism diagnosis either concurrently or consequently were eligible at the date of discharge (index date). Those patients registered with the provincial drug plan and discharged to the community were included in the study and followed for 6 months. Results: Among 2,070 study patients, 72.4% received anticoagulant therapy at index date, 60% of whom were persistent with therapy and received it for ≥80% of follow-up days. Outpatient anticoagulant use was more likely in those with primary versus secondary diagnosis of venous thromboembolism and less likely in patients with cerebrovascular disease, peptic ulcer disease or previous anticoagulant use. The small number of patients who used either UFH (n=11) or fondaparinux (n= 5) at index date were included in the LMWH group. Warfarin use was less likely than LMWH use in corticosteroid users, previous anticoagulant users, patients with metastatic cancer and those with catheter or chemotherapy in the previous three months. Warfarin use was more likely than LMWH use in: older patients, those residing in rural areas, those with lower income and those suffering from ischemic heart disease, atrial fibrillation or chronic kidney disease. Patients with ischemic heart disease were more likely to have used a non-dalteparin LMWH versus dalteparin (currently, the only LMWH approved by health Canada for chronic treatment of VTE), while those residing in rural areas and those with catheter/chemotherapy were less likely to have used them. A primary (versus secondary) discharge diagnosis of venous thromboembolism [Odds Ratio 1.42; 95% confidence interval (1.14, 1.76)], and metastatic cancer 1.27 (1.00, 1.60) were associated with persistence on anticoagulant treatment. Conclusion: Guideline recommended outpatient use of anticoagulant in cancer patients hospitalized with venous thromboembolism was influenced by cancer status, old age and low income. Risk factors for bleeding prevented outpatient anticoagulant use in some patients

Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index : a study protocol for a before/after intervention with a retrospective control group and multiple case analysis.

Introduction Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. Methods and analysis This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2 , analysis of variance and unadjusted and adjusted regression methods. Ethics and dissemination Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conference

The delicate choice of optimal basic therapy for multimorbid older adults : a cross-sectional survey

Background: Clinical practice guidelines are useful to suggest pharmacological therapies for the treatment of single chronic diseases. However, there is little guidance for multimorbidity, and specific quality measures for people with multimorbidity that can be used at a population level are lacking. Objective: To describe what pharmacists and geriatricians consider to be an optimal basic pharmacological therapy for an older individual with type 2 diabetes (DM), chronic obstructive pulmonary disease (COPD) and heart failure (HF). Methods: An online cross-sectional survey among 162 pharmacists and geriatricians, in Quebec, Canada, was performed. Participants were invited to choose, from a list of 32 medications or classes, the optimal basic therapy for an individual aged 65–75 years with the 3 chronic diseases. Descriptive statistics were used to calculate the median number of medications chosen and the proportions of participants who chose each medication, according to the participant's specialty. A Kruskall-Wallis test was performed to detect whether there were differences in the median number of medications recommended according to speciality. Results: There was little consensus on the optimal basic pharmacological therapy for this hypothetical multimorbid individual, with 157 different combinations provided by the 162 participants. Nevertheless, 5 classes were chosen by at least 75% of the participants: metformin, long-acting anticholinergic agents, angiotensinconverting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta-blockers, and short-acting betaagonists. The median number of recommended medications was 10 (interquartile range [IQR]: 6–13). There was a statistically significant difference between specialties (p = 0.0396). Geriatricians recommended the lower median number of medications, 7 (IQR: 5–10). Conclusions: At least half of the participants considered polypharmacy (≥10 medications) inevitable for an optimal basic treatment of DM, COPD and HF. The heterogeneity of responses raises issues when considering quality indicators in population-based studie

Pharmacoepidemiology in older people : purposes and future directions

Knowledge of the benefit/risk ratio of drugs in older adults is essential to optimise medication use. While randomised controlled trials are fundamental to the process of drug development and bringing new drugs to the market, they often exclude older adults, especially those suffering from frailty, multimorbidity and/or receiving polypharmacy. Therefore, it is generally unknown whether the benefits and harms of drugs established through pre-marketing clinical trials are translatable to the real-word population of older adults. Pharmacoepidemiology can provide real-world data on drug utilisation and drug effects in older people with multiple comorbidities and polypharmacy and can greatly contribute towards the goal of high quality use of drugs and well-being in older adults. A wide variety of pharmacoepidemiology studies can be used and exciting progress is being made with the use of novel and advanced statistical methods to improve the robustness of data. Coordinated and strategic initiatives are required internationally in order for this field to reach its full potential of optimising drug use in older adults so as to improve health care outcomes

Association between nutrition and the evolution of multimorbidity : the importance of fruits and vegetables and whole grain products

Background & aims: Multimorbidity is a common health status. The impact of nutrition on the development of multimorbidity remains to be determined. The aim of this study is to determine the association between foods, macronutrients and micronutrients and the evolution of multimorbidity. Methods: Data from 1020 Chinese who participated in the Jiangsu longitudinal Nutrition Study (JIN) were collected in 2002 (baseline) and 2007 (follow-up). Three-day weighted food records and status for 11 chronic diseases was determined using biomedical measures (hypertension, diabetes, hypercholesterolemia and anemia) or self-reports (coronary heart disease, asthma, stroke, cancer, fracture, arthritis and hepatitis). Participants were divided in six categories of stage of evolution of multimorbidity. Association of foods, macronutrients and micronutrients at baseline with stages in the evolution of multimorbidity were determined. Data were adjusted for age, sex, BMI, marital status, sedentary lifestyle, smoking status, annual income, education and energy intake. Results: The prevalence of multimorbidity increased from 14% to 34%. A high consumption of fruit and vegetables (p < 0.05) and grain products other than rice and wheat (p < 0.001) were associated with healthier stages in the evolution of multimorbidity. The consumption of grain products other than rice and wheat was highly correlated with dietary fibers (r ¼ 0.77, p < 0.0001), iron (r ¼ 0.46, p < 0.0001), magnesium (r ¼ 0.49, p < 0.0001) and phosphorus (r ¼ 0.57, p < 0.0001) intake which were also associated with healthier stages. Conclusion: This study provides the first evidence of an association between nutrition and evolution towards multimorbidity. More precisely, greater consumption of fruits and vegetable and whole grain products consumption appear to lower the risk of multimorbidity

Qualité du traitement cardioprotecteur du diabète de type 2 chez les aînés québécois et son impact sur la morbidité cardiovasculaire

Tableau d’honneur de la Faculté des études supérieures et postdoctorales, 2010-2011Le diabète de type 2 constitue une menace importante pour la santé publique, notamment parce qu'il engendre plusieurs complications cardiovasculaires. Les aînés sont particulièrement frappés par le diabète de type 2 et ses complications. Les médicaments cardioprotecteurs (antihypertenseurs, hypolipémiants et antiplaquettaires) peuvent réduire le fardeau des maladies cardiovasculaires, mais on connaît peu la façon dont ces médicaments sont utilisés par les aînés québécois et comment ils influencent leur santé. La thèse a pour objectif général de décrire l'usage de médicaments cardioprotecteurs dans le traitement du diabète de type 2 chez les aînés du Québec, et de déterminer l'impact des médicaments cardioprotecteurs sur la morbidité cardiovasculaire. Les bases de données administratives détenues ou gérées par la Régie de l'assurance maladie du Québec constituent les sources de données. La population à l'étude comprend les aînés de 66 ans et plus ayant débuté un antidiabétique oral entre le 1er janvier 1998 et le 31 décembre 2003. Trois études de cohorte ont été réalisées pour décrire l'usage des médicaments cardioprotecteurs dans l'année suivant l'initiation du traitement antidiabétique. Ensuite, une étude cas-témoins imbriquée dans la cohorte a été effectuée pour déterminer l'effet des médicaments cardioprotecteurs sur les infarctus du myocarde (IM) et les accidents vasculaires cérébraux (AVC). Deux autres études cas-témoins ont enfin été réalisées pour évaluer l'effet de l'aspirine sur les IM et les saignements gastrointestinaux. Le pourcentage d'individus utilisant les trois médicaments cardioprotecteurs s'élevait à 20,4%. Les plus forts prédicteurs de l'usage combiné de ces médicaments étaient l'usage antérieur d'antihypertenseurs [rapports de cotes (RC) = 1,6; LC. 95%: 1,4-1,7], d'hypolipémiants (7,4; 6,8-8,0) et d'antiplaquettaires (7,3; 6,7-7,9). Pour chaque période de 30 jours où les individus étaient exposés à une combinaison de médicaments cardioprotecteurs, le risque d'IM et d'AVC était diminué de 2% (RC : 0,98; 0,96-1,00). Toutefois, l'usage d'aspirine n'influençait pas le risque d'IM (1,16; 0,98-1,37), mais exposait à un risque accru de saignements gastro-intestinaux (1,94; 1,47-2,57)