Faculty Disclosure Monte SV discloses ownership in Mobile Pharmacy Solutions.

A Review of Interventions to Reduce Polypharmacy in the Elderly: Lost in Translation?Baumgartner A , Verni C, LaValley S, Wahler RG, Monte SV, Singh R.

Statement of Problem

Materials and Methods

Design: Narrative review of high quality studies of medication safety interventions with older adults.Sources: Relevant abstracts in PubMed dated between 2000 and 2017 using MESH headings, “Drug-related side effects AND Adverse Reactions AND Aged AND Intervention.” Inclusion Criteria:• RCT or prospective cohort study design• Medication Safety Intervention• Involved the elderly in their study population• Measured ED visits and/or hospitalization rates as

outcome measures• Had completed resultsExclusion Criteria:• Limited to a single disease conditionAnalysis:• Included articles were analyzed for discussion of

factors relevant to implementation, as defined by the Consolidated Framework for Implementation Research (CFIR)

• Each implementation factor, and their assigned CFIR domain, was independently identified by 2 reviewers and disagreements were resolved by discussion

• Process measures and intermediate outcomes were also identified

Results

Conclusion

References

www.buffalo.edu

Objective

PRISMA Chart

Future Implications

• To assess the extent to which the literature

described and explored factors relevant to

successful intervention implementation. Study findings:• Study settings included hospital (n=4), skilled nursing (n=2), and outpatient (n=4)• Intervention types included medication review (n=7), and clinical decision support (n=2)• 1/10 MSIs improved ED visits and/or hospitalization rates (after post-hoc analysis)

Attention to implementation process:• 6/10 papers discussed implementation factors that could be identified in the CFIR but

very few of the potential factors in CFIR were touched upon (see Chart)• 8/10 studies presented process measures / intermediate outcomes but this was done in

an inconsistent way (see Table)

• Potentially inappropriate prescribing represents a significant risk to patients, including emergency department visits and hospitalizations

• Evidenced based criteria, such as the Beers and START/STOP criteria, have had difficulty being implemented into everyday practice

• Medication safety interventions (MSIs) designed to implement these practices have had inconsistent results, particularly when measuring emergency department visits and hospitalizations as the primary outcome

Author Process measure / intermediate

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Surgery and

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Lapane XLenander X XLeenderstse X X

Touchette XDonovan

Farris X X

CFIR Constructs and Factors Identified

Intervention Characteristics:Evidence Strength and Quality: (1) • Intervention limited to 5 high risk meds

Outer Setting:Patient Needs and Resources: (2)• ADE rate in surgical patients• Pre-intervention med adherence

Inner Setting:Networks and Communication (6)• Pharmacist integration **• Patient-Pharmacist relationshipAvailable Resources (1)• Logistical strain on the pharmacist• Time per patient

Process:Reflecting and Evaluating: (2)• Evaluation of intervention process limitations• Impact of inclusion criteria

Characteristics of IndividualsOther Personal Attributes: (1)• Pharmacist educational background

• Translational gap: Our review of high quality MSI studies confirms that evidenced based practices have difficulty being translated into the clinical setting

• Unclear impact of MSIs: Most studies failed to show an impact on hospitalizations and ED visits

• Process of implementation not adequately addressed: Therefore, a possible explanation for the lack of clear impact of MSIs the outcomes measured is that their effect was lost in translation.

1. Budnitz, D.S., et al., Emergency Hospitalizations for Adverse Drug Events in Older Americans. New England Journal of Medicine, 2011. 365(21): p. 2002-2012.2. Gallagher, P., et al., STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther, 2008. 46(2): p. 72-83.3. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.J Am Geriatr Soc, 2015. 63(11): p. 2227-46.4. Onder, G., et al., Strategies to reduce the risk of iatrogenic illness in complex older adults. Age Ageing, 2013. 42(3): p. 284-91.5. Ovretveit, J.C., et al., How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. BMJ Qual Saf, 2011. 20(7): p. 604-10.6. Damschroder, L.J., et al., Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci, 2009. 4: p. 50.7. Leendertse, A.J., et al., Preventing hospital admissions by reviewing medication (PHARM) in primary care: an open controlled study in an elderly population. J Clin Pharm Ther, 2013. 38(5): p. 379-87.8. Kjeldsen, L.J., et al., Evaluation of a controlled, national collaboration study on a clinical pharmacy service of screening for risk medications. Int J Clin Pharm, 2014. 36(2): p. 368-76.9. Farris, K.B., et al., Effect of a care transition intervention by pharmacists: an RCT. BMC Health Serv Res, 2014. 14: p. 406.10. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1). doi:10.1186/1748-5908-4-50

KEY:

CFIR Construct Category:CFIR Construct (# of mentions) • Specific factor identified in the

literature

• A systematic approach: Studies should be designed with appreciation for the role of the implementation process. This may provide more fruitful analysis as well as providing benchmark process measures for future comparison.

• Multi-pronged analysis: A combination of patient outcomes, process outcomes, and qualitative analysis can be used synergistically to fully evaluate the implementation process

• CFIR as a tool: CFIR can be applied to medication safety interventions to accomplish these goals.

Records identified (PubMed)(n = 387)

Records screened(n = 387)

Records Excluded(n = 351)

Full-text articles assessed for eligibility(n = 36)

Full-text articles excluded(n = 26)

Studies included in qualitative synthesis(n = 10)