Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis.

BACKGROUND: Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics. METHODS: We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020. RESULTS: We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits). CONCLUSIONS: Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.

Understanding the early effects of team-based learning on student accountability and engagement using a three session TBL pilot.

BACKGROUND AND PURPOSE: This study examined the early effects of a team based learning (TBL) pilot, including differences in student engagement with TBL compared to lectures, and student accountability, preferences, and satisfaction with TBL. EDUCATIONAL ACTIVITY AND SETTING: Three TBL sessions were delivered in the nephrology section of pharmacotherapy and then students completed the team-based learning student assessment instrument (TBL-SAI), which assesses TBL relative to lecture on three subscales (i.e., student accountability, preferences, and satisfaction). Students also completed a modified engagement instrument for a lecture and again for a TBL session. FINDINGS: All students (160) participated in the survey (100% response rate). When comparing TBL and lecture engagement, five of eight statements were statistically significantly different. In TBL, students reported the strongest agreement with statements related to contributions (i.e., contributing fair share [mean 3.97], contributing meaningfully [mean 3.96]). Using the TBL-SAI, the mean score for accountability (30.64) was higher than neutral (24) indicating a higher level of accountability with TBL. Student satisfaction with TBL was neutral (mean 26.62, neutral = 27). DISCUSSION AND CONCLUSIONS: In a three-session pilot, TBL had positive effects on engagement and accountability. Early positive effects could aid programs in building and maintaining momentum with the TBL approach while working towards outcomes that may take longer to achieve, such as changes in professionalism or teamwork. Duration of exposure and perseverance through the transition to TBL may be important in developing preferences and satisfaction. This study provides insights to programs and instructors about student perceptions and attitudes as TBL is introduced.

Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%.

Anemia treatment with epoetin has led to dramatic increases in hematocrit levels since 1989. Studies have demonstrated that morbidity and mortality rates are lower when hematocrit values are within the Disease Outcomes Quality Initiative (DOQI) target range (33 to 36%). Recently, clinical studies demonstrated that patients without cardiovascular disease exhibited lower morbidity rates and improved cognitive function with hematocrit values of >36%. One prospective trial, in contrast, demonstrated that normal hematocrit values among patients with cardiac disease were associated with higher mortality rates. These conflicting results have led to concerns regarding the risks and benefits associated with hematocrit values between 36 and 42%. To address these concerns, a recent cohort of 1996 to 1998 incident hemodialysis patients was studied, with assessments of the risks of death and hospitalization and the medical costs associated with hematocrit values of >36%. Patients survived at least 9 mo after dialysis initiation, and comorbidity, disease severity, and hematocrit levels were determined for months 4 to 9. Patients were grouped on the basis of hematocrit values, i.e., <30, 30 to <33, 33 to <36, 36 to <39, or > or =39%, with 1 yr of follow-up monitoring. A Cox regression model was used to evaluate all-cause and cause-specific mortality and hospitalization rates. The economic evaluations included analyses with Medicare Parts A and B allowable expenditures as the dependent variable and the same clinical characteristics as independent variables. For patients with hematocrit values of > or =36%, mortality rates were not different, hospitalization rates were 16 to 22% lower, and expenditures were 8.3 to 8.5% less, compared with patients with hematocrit values of 33 to <36%. These observations do not demonstrate causality. Additional long-term studies are needed to assess the risks of higher hematocrit values among all patients and patients with cardiovascular disease.