Healthy Outcomes through Peer Educators: Feasibility of a peer support diabetes prevention programme for African-American grandmother caregivers.

AIM: To assess the protocol feasibility and intervention acceptability of a community-based, peer support diabetes prevention programme (DPP) for African-American (AA) grandmother caregivers at risk for diabetes. MATERIALS AND METHODS: Grandmother caregivers were randomized in a 2:1 ratio to DPP (active comparator) or DPP plus HOPE (Healthy Outcomes through Peer Educators; intervention). DPP + HOPE incorporated support from a peer educator who met with participants in person or by telephone every week during the 1-year intervention. Outcomes included: (1) recruitment rates, outcome assessment, and participation adherence rates assessed quantitatively; and (2) acceptability of the programme assessed through end-of-programme focus groups. RESULTS: We successfully consented and enrolled 78% (n = 35) of the 45 AA grandmothers screened for eligibility. Eighty percent of participants (aged 64.4 ± 5.7 years) were retained up to Week 48 (74% for DPP [n = 17] and 92% for DPP + HOPE [n = 11]). All grandmothers identified social support, neighbourhood safety, and access to grocery stores as influences on their health behaviours. At Month 12, the active comparator (DPP) group and the intervention group (DPP + HOPE) had a mean change in body weight from baseline of -3.5 ± 5.5 (-0.68, -6.29) kg and - 4.4 ± 5.7 (-0.59, -8.2) kg, respectively. CONCLUSIONS: This viable study met the aim of educating and equipping AA grandmothers with the practical and sustained support needed to work toward better health for themselves and their grandchildren, who may be at risk for diabetes. The intervention was both feasible and acceptable to participating grandmothers and their organizations.

Improving pain communication between limited English-speaking Hmong patients, medical interpreters, and health care providers in primary care: A pilot study.

This pilot study assessed the feasibility of implementing a pain assessment information visualization (InfoViz) tool to address cultural and language barriers among limited English proficiency (LEP) Hmong patients in primary care. We used a static group comparison design to collect data from 20 patient, interpreter, and provider triads under usual care (i.e., interpreter using verbal pain descriptions), followed by another 20 triads under the intervention (i.e., interpreter using verbal pain descriptions and the InfoViz tool). Feasibility outcomes included recruitment and retention rates, InfoViz tool completion, acceptability, and fidelity. We also assessed mutual understanding (MU) and pain electronic health record (EHR) documentation. Descriptive data were calculated and thematic analysis was conducted. Thirty-six LEP Hmong patients (n = 29 female, mean age = 59.03), 27 providers (n = 15 female), and four interpreters participated in this study. The patient recruitment rate was 18% while the retention rate was 81%. Interpreter recruitment rate was 80%, and 75% for retention rate. The intervention fidelity mean score was 83%. In the intervention condition, patient-provider MU of pain severity improved by 30%, coupled with a 28% increase in pain severity EHR documentation compared to usual care. While communication of pain quality did not improve, there was a higher mean number of pain descriptors (3.31 in the intervention vs. 1.79 in usual care) in EHR documentation. All participants had a positive experience with the tool, reporting it as valuable with 100% completeness of all tools. Findings revealed the tool was acceptable and feasible to use among LEP patients-interpreters-providers, providing support for an efficacy study.

Chasing a dream against all odds.

BACKGROUND: Youth of color growing up in poverty face many challenges that children from more affluent families never experience. These children often reside in disadvantaged neighborhoods with substandard housing, inadequate medical care, and under resourced schools. This places these children at risk for poor academic achievement, school dropout, abuse and neglect, behavioral and socioemotional problems, and physical health problems. In spite of these risks, some children "beat the odds" and overcome the challenges and adversities in their external contexts. The paper reports the findings of a draw-and-write activity designed to learn the processes whereby protective factors promote resilience from a child's point of view. METHODS: In this qualitative study, a draw-and-write activity was conducted with a convenience sample of 33 children, (23 females and 10 males of which 10 were Hmong, 11 were Middle Eastern, and 12 were African Americans) .The children were asked to make visual representations of resources (persons or things that, in their view, contribute to their wellbeing.) In depth interviews with a subset of 15 of the children was conducted to discuss the meaning of the images in their drawings. A summative content analysis of the visual and narrative data was performed using a resilience framework. RESULTS: Regardless of racial/ethnic background, parents, and especially mothers, were the main "person or thing" identified by these children living in poverty as helping them "make it thus far in life." Ninety seven percent of the participants in this study described their parent(s) as nurturing and supportive, enabling them to overcome obstacles and adversities within their environment. Forty five percent of participants identified their mother as a key anchor in their life Fifty eight percent of the African American children indicated that their parent(s) encouraged education to escape poverty. CONCLUSION: The findings support that families, particularly parents have the strongest influence on supporting the resilience process in a child. These findings were consistent across ethnicity and gender. Families, particularly parents, should be the target of future interventions designed to produce resilient behaviors in youth of color living in poverty.

Handout use to facilitate opioid risk and safety communication in community pharmacies.

BACKGROUND: A number of opioid handouts exist for pharmacists to use for patient education. However, there is limited evidence about what pharmacists most want them to cover and how useful pharmacists perceive them to be. OBJECTIVES: This study sought to (1) refine and revise an opioid safety handout to facilitate opioid risks and safety communication in community pharmacies and (2) assess the feasibility and acceptability of this tool using a statewide survey of community pharmacists. METHODS: In phase 1, 8 community pharmacists were interviewed to refine and evaluate the opioid safety handout. In phase 2, a statewide sample of 700 pharmacists were surveyed to identify acceptability and feasibility of using the revised handout. Survey data were analyzed using descriptive statistics and multiple regression analysis. RESULTS: A total of 140 surveys were returned from community pharmacists. Over 60% of pharmacists reported that the handout would be useful in counseling patients on opioid risks and safety and would be a good opioid education tool for patients. Pharmacists who had practiced for many years (P = 0.002) and pharmacists who discussed safe opioid disposal and storage regularly (P = 0.002) reported a higher likelihood of using the handout. Pharmacists were much more likely to counsel patients on opioid risks and safety using this handout for a long-term opioid prescription than for a short-term opioid prescription. CONCLUSION: A participatory research design successfully refined a handout for opioid risks and safety counseling, which the majority of pharmacists evaluated as feasible and useful for community pharmacists.

Pharmacist roles, training, and perceived barriers in naloxone dispensing: A systematic review.

OBJECTIVES: Pharmacists are well positioned to identify patients at risk of overdose, dispense naloxone, and counsel patients on appropriate use. In response to growing numbers of opioid-related deaths, many states have issued standing orders allowing pharmacists to dispense naloxone without a prescription. This systematic review examines the current state of naloxone use and dispensing regarding (1) roles for pharmacists dispensing naloxone, (2) barriers to their dispensing naloxone, and (3) pharmacist training to dispense naloxone. DATA SOURCES: PubMed, Cinahl Plus, and Cochrane review databases were searched with the use of the terms "pharmacist OR pharmacy" AND "naloxone." Included for review were peer-reviewed original research studies conducted in the U.S. in the past 5 years. STUDY SELECTION: The preliminary search generated 155 studies, including 50 duplicate studies which were removed. From the remaining 105 studies, 33 were included that addressed pharmacist naloxone dispensing roles, barriers and facilitators to dispensing, or training for pharmacists. DATA EXTRACTION: Authors, publication year, study title, study objective, method, outcomes, and conclusions were extracted for all studies. RESULTS: Out of 33 studies, 14 focused on pharmacists' roles in naloxone dispensing, 9 on barriers, and 10 on training pharmacists for dispensing naloxone. The review found that most states permit major naloxone dispensing roles for pharmacists, but pharmacists are often underutilized without programs to support their roles. A key barrier to pharmacist naloxone dispensing is limited pharmacist training to identify and educate patients at risk of overdose. CONCLUSION: Although pharmacists have the legal opportunity to educate patients and dispense naloxone, barriers have limited their addressing naloxone with patients. There is a need for more intervention studies and in-depth understanding of pharmacist perspectives on barriers, training, and professional roles to facilitate tailored approaches for increasing pharmacist confidence in naloxone dispensing and consultation.

Pharmacy intervention to facilitate transparent opioid-risk and safety communication.

OBJECTIVE: This paper seeks to explore the impact of training, a handout, and patients' questions on pharmacists' comfort and satisfaction in discussing opioid risks with pediatric caregivers. METHODS: In a mixed methods intervention study in a children's hospital outpatient pharmacy, 2 practicing pharmacists and 1 student pharmacist counseled 100 caregivers using their standard practices (not telling a caregiver the pain medicine was an opioid or informing them about opioid risks). After the training, the same 2 pharmacists and another student pharmacist counseled 97 caregivers about opioid-risk by assessing their beliefs, explaining that the medication was an "opioid," and integrating a safety handout into the consult. The pharmacists completed short surveys after each consult in both phases and were interviewed. Qualitative data were coded using NVivo version 12 (QSR International). Descriptive statistics and multivariate regression analyses were performed on the data collected from the surveys. RESULTS: During the preintervention phase, opioid risks were not discussed; no pharmacist described the pain medication as an opioid. The pharmacists reported that they needed training and resources to assist opioid counseling. In the postintervention phase, the pharmacists indicated that the medication was an opioid in all consults. The pharmacists' comfort increased significantly over time and decreased with caregivers' concerns at posttest (adjusted R2 = 0.40). The pharmacists' satisfaction increased with time and caregiver questions (adjusted R2 = 0.15). The pharmacists reported that the training and handout facilitated opioid-risk and safety discussions. CONCLUSION: The intervention positively affected pharmacists' comfort and satisfaction. It should be evaluated in different settings and populations.

Impact of family-centered tailoring of pediatric diabetes self-management resources.

BACKGROUND: The American Diabetes Association recommends a family-centered approach that addresses each family's specific type 1 diabetes self-management barriers. OBJECTIVE: To assess an intervention that tailored delivery of self-management resources to families' specific self-management barriers. SUBJECTS: At two sites, 214 children 8-16 years old with type 1 diabetes and their parent(s) were randomized to receive tailored self-management resources (intervention, n = 106) or usual care (n = 108). METHODS: Our intervention (1) identified families' self-management barriers with a validated survey, (2) tailored self-management resources to identified barriers, and (3) delivered the resources as four group sessions coordinated with diabetes visits. Mixed effects models with repeated measures were fit to A1c as well as parent and child QOL during the intervention and 1 year thereafter. RESULTS: Participants were 44% youth (8-12 years) and 56% teens (13-16 years). No intervention effect on A1c or QOL was shown, combining data from sites and age groups. Analyzing results by site and age group, post-intervention A1c for teens at one site declined by 0.06 more per month for intervention teens compared to usual care (P < 0.05). In this group, post-intervention A1c declined significantly when baseline A1c was >8.5 (-0.08, P < 0.05), with an even larger decline when baseline A1c was >10 (-0.19, P < 0.05). In addition, for these teens, the significant improvements in A1c resulted from addressing barriers related to motivation to self-manage. Also at this site, mean QOL increased by 0.61 points per month more during the intervention for parents of intervention youth than for usual care youth (P < 0.05). CONCLUSIONS: Tailored self-management resources may improve outcomes among specific populations, suggesting the need to consider families' self-management barriers and patient characteristics before implementing self-management resources.

Improving health care communication for caregivers: A pilot study.

With the growing older adult population, there will also be more informal caregivers assisting friends and family with their health care. With the increasing complexity of health care, improved caregiver communication skills have the potential to reduce caregiver burden and frustration and improve care recipient health. The primary goal of this project was to develop and refine the content and teaching methods of a small-group behavioral change program to improve communication between caregivers of older adults and health care professionals. The authors developed the Care Talks program for improving communication between caregivers and health care professionals. They conducted a prospective cohort feasibility study of the intervention to assess caregiver communication confidence at baseline and one month postintervention. Six participants were enrolled. Of the 15 participants who answered the question, 15 (100%) would recommend this program to a friend. There was significant improvement in a 10-question composite of communication confidence pre/post scores from 74.1 to 79.6 p = .03. This small-group behavioral change intervention significantly improved communication confidence for this sample of caregivers. Further research is needed to determine the long-term effects of this program on caregivers and care recipients.

Asthma medication use among late midlife U.S. Adults.

OBJECTIVE: Despite substantial prevalence of asthma, little is known about asthma in late midlife adults (50-64 years). The objective of this study was to examine the factors associated with the use of asthma medications among late midlife adults. METHODS: Pooled data were obtained from the 2006 to 2010 Medical Expenditure Panel Survey. Medication use outcome variables include: (a) daily use of a preventive asthma medication and (b) use of more than three canisters of rescue inhalers in last 3 months. The Andersen Behavioral Model of Health Services Utilization was used to guide the selection of independent variables. Descriptive, unadjusted and adjusted logistic regression analyses were performed. Point estimates were weighted to the US civilian population and variance estimates were adjusted to obtain appropriate standard errors. All analyses were conducted using STATA (version 12). RESULTS: A total of 1414 (weighted sample of 15,030,364) self-reported late midlife asthmatics were identified. About 31% of late midlife adults with asthma were using a preventive medication on a daily basis while 11% reported overusing acute medications. Adjusted analyses found that race, rurality and smoking were related to poor use of asthma medications among late midlife adults. CONCLUSION: Results suggest that asthma medication use is far from optimal among vulnerable groups of late midlife US adults.

Exploring the impact of a digital health tool on patients' interaction with community pharmacists: A pilot randomized controlled study.

BACKGROUND: The use of digital Patient- Reported Outcomes (PRO) tools has been shown to enhance the exchange of information and shared decision-making in medical encounters. However, their influence on patient-pharmacist interactions has not yet been explored. OBJECTIVES: This study aimed to examine the impact of RxTalk™, a digital PRO tool, in supporting the communication between patients and pharmacists compared to usual care. METHODS: Intervention: RxTalk™ was developed to collect information about medication adherence and beliefs, using a tablet computer. STUDY DESIGN: A pilot randomized controlled study was conducted at a community pharmacy in Wisconsin, USA. Sixty patients were randomized to either the intervention group who used RxTalk™ during medication pick-up or the control group who did not use the tool. Patients who used RxTalk™ received paper copies of their responses which were also shared with pharmacists. The consultation was audio-recorded for both groups and coded using the Active Patient Participation Coding scale. Follow-up phone interviews were conducted with both groups within one week of enrollment. RESULTS: Patient tapes were analyzed. In the unadjusted model, patients in the intervention group had a higher active participation rate (p = 0.004) and raised significantly more concerns during consultations (p < 0.001) compared to the control group. Pharmacists asked twice as many questions while counseling patients in the intervention group compared to the control group (p < 0.001). After controlling for patients' demographics and pharmacists' questions, there was a statistical difference between the two patient groups in their odds of expressing at least one concern utterance. CONCLUSION: This pilot study suggests that collecting PRO from patients with chronic illnesses and providing results to pharmacists and patients can help patients express their health and medication concerns. RxTalk™ would be useful for pharmacists who wish to improve the recognition and management of medication-related problems.

Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares.

OBJECTIVE: Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. METHODS: HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. RESULTS: Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. CONCLUSION: An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy.

Perspectives on Self-Management and Meditation: A Qualitative Study of Adolescents With Type 1 Diabetes Mellitus and Their Parents.

BACKGROUND: One in three adolescents with type 1 diabetes mellitus (T1DM) experiences diabetes distress, which predicts poor self-management and glycemic control. Mindfulness-based interventions such as meditation have been associated with reduced psychological distress and health outcomes in different populations. This study explores the psychosocial barriers and facilitators of diabetes self-management and beliefs about meditation practices. METHODS: Eight adolescents aged 15-19 who had been diagnosed with T1DM for more than a year were invited to participate in a 40-60-minute semi-structured one-on-one interview. Their parents were also invited to participate in the study. Three of the eight parents invited were able to participate in the study. Participants were asked about perceived psychosocial barriers and facilitators of diabetes self-management and their beliefs about meditation as a tool for addressing some of the psychosocial barriers to self-management. Data were analyzed using NVivo 10 (QSR International, Melbourne, Australia). Conventional content analysis was conducted based on an inductive coding approach. RESULTS: Adolescents with T1DM had similar psychosocial challenges with managing T1DM, including high levels of diabetes distress and forgetfulness due to competing demands on their time. They also noted similar facilitators to effective self-management, such as the presence of family and peer support. Acceptance of T1DM diagnosis and personal commitment to self-management were also indicated as common facilitators of self-management. Adolescents with T1DM and parents of adolescents with T1DM believe that meditation can play a positive role in T1DM self-management by reducing diabetes distress and improving mental health and overall well-being. CONCLUSION: Results suggest that adolescents with T1DM and parents of adolescents with T1DM believe peer and family support is crucial to diabetes self-management. They also noted that diabetes distress and forgetfulness are primary barriers to self-management. Participants also see a potential for meditation to help manage general stress and diabetes distress, thereby aiding self-management. Further research is needed to explore meditation-based interventions to reduce diabetes distress in adolescents diagnosed with T1DM. The findings from this study can inform the development and implementation of meditation-based interventions that integrate family and peer support to reduce diabetes distress and enhance self-management in adolescents with T1DM.

Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus.

OBJECTIVE: Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits. METHODS: HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (<750 ng/mL), (2) therapeutic (750-1,200 ng/mL), or (3) supratherapeutic (>1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care. RESULTS: A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use. CONCLUSION: HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus.

Enhancing older Veterans' care: Insights from medication reviews and deprescribing interventions.

BACKGROUND: Patient experience during and after health care is a critical indicator of quality of care that encompasses effective communication, respect, dignity, and emotional support. However, qualitative studies exploring the experiences of older adults after deprescribing interventions are sparse, highlighting a knowledge gap. This project seeks to address this gap by exploring Veterans' experiences during and after a deprescribing intervention provided by a pharmacist. This study aims to: 1. Assess Veteran's experience of the process of their Comprehensive Medication Review and deprescribing intervention visit; 2. Assess the Veteran's experience with the outcomes of their Comprehensive Medication Review and deprescribing intervention. METHOD: Data was collected from 17 Veterans through semi-structured interviews using an interview guide. The Veteran Affairs study site utilizes the VIONE polypharmacy risk calculator to identify high-risk Veterans; the majority of these Veterans were on at least 10 medications. The interview transcripts were analyzed using inductive content analysis. Two research team members independently coded the data for categories and themes. Similarities were identified, and any divergence was discussed and resolved. To enhance the validity of the findings, member checking was performed with Veterans to confirm the results. RESULT AND DISCUSSION: Most Veterans viewed the process of the pharmacists' visits and recommendations positively. They expressed confidence in pharmacists' knowledge and instructions. They appreciated the clarity of information pharmacists provided about the purpose, proper administration, and interactions of their medications. These enhanced the Veterans' ability to manage their medication regime. They also desired an increased frequency of interactions with their pharmacist due to these positive interactions. Veterans appreciated interprofessional collaboration between pharmacists, physicians, and other providers. Veterans expressed how pivotal lab test results were for evaluating medication recommendations and effectiveness. Most Veterans reported positive outcomes and/or indicated there were no negative effects as a result of their recent medication changes. Some reported seeking additional information from their providers regarding suggested medication changes to validate recommendations. There was some uncertainty about whether there would be follow-up visits with the professional after the medication change and who should initiate this. A minority indicated problems associated with prior medication discontinuation before the deprescribing intervention and how this limited their openness to future opportunities of deprescribing. CONCLUSION: This exploration of Veterans' experiences with the process and outcomes of a deprescribing service affirms its importance and overall success in this site as part of the unique publicly funded Veteran healthcare system in the US. Equally important, the positive Veteran response suggests the value of exploring its potential to benefit patients experiencing polypharmacy across a range of other sites and systems.

Protective factors in American Indian communities and adolescent violence.

With their distinct cultural heritage and rural boundaries, American Indian reservation communities offer a unique opportunity to explore protective factors that help buffer adolescents from potential risk behaviors such as violence. Prior published research on Indian communities has not explored three potential protective factors for violence-parental monitoring of adolescents and friends, adolescents' self-efficacy to avoid fighting, and adolescents' interest in learning more about their traditional culture. This paper explores the relationship between these factors and reduced risk of reported violence. In 1998, 630 American Indian students in grades 6-12 were surveyed in five Midwestern, rural Indian reservation schools. Path analysis was used to identify the direct and indirect association of the three potential protective factors with reduced violence behavior. There were significant gender differences both in perceived parental monitoring and in adolescents' self-efficacy. For female adolescents, parental monitoring had the strongest inverse relationship with female adolescents' involvement in violence. Female adolescents' self-efficacy and their interest in learning more about their culture were also inversely associated with violence and therefore potentially important protectors. Male adolescents who reported more interest in learning the tribe's culture had better self-efficacy to avoid violence. However, self-efficacy did not successfully predict their reported involvement in peer violence. These findings support exploring gender differences, parental monitoring, self-efficacy training as well as cultural elements in future violence intervention studies. Further investigation is needed to identify protective factors for risk behaviors among male adolescents and test the generalizability to non-reservation based adolescents.

A systematic review of randomised-controlled trials on deprescribing outcomes in older adults with polypharmacy.

BACKGROUND: Mixed findings about deprescribing impact have emerged from varied study designs, interventions, outcome measures and targeting sub-categories of medications or morbidities. This systematic review controls for study design by reviewing randomised-controlled trials (RCTs) of deprescribing interventions using comprehensive medication profiles. The goal is to provide a synthesis of interventions and patient outcomes to inform healthcare providers and policy makers about deprescribing effectiveness. OBJECTIVES: This systematic review aims to (1) review RCT deprescribing studies focusing on complete medication reviews of older adults with polypharmacy across all health settings, (2) map patients' clinical and economic outcomes against intervention and implementation strategies and (3) inform research agendas based on observed benefits and best practices. METHODS: The PRISMA framework for systematic reviews was followed. Databases used were EBSCO Medline, PubMed, Cochrane Library, Scopus and Web of Science. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised trials. RESULTS: Fourteen articles were included. Interventions varied in setting, preparation, use of interdisciplinary teams, validated guidelines and tools, patient-centredness and implementation strategy. Thirteen studies (92.9%) found deprescribing interventions reduced the number of drugs and/or doses taken. No studies found threats to patient safety in terms of primary outcomes including morbidity, hospitalisations, emergency room use and falls. Four of five studies identifying health quality of life as a primary outcome found significant effects associated with deprescribing. Both studies with cost as their primary outcome found significant effects as did two with cost as a secondary outcome. Studies did not systematically study how intervention components influenced deprescribing impact. To explore this gap, this review mapped studies' primary outcomes to deprescribing intervention components using the Consolidated Framework for Implementation Research. Five studies had significant, positive primary outcomes related to health-related quality of life (HRQOL), cost and/or hospitalisation, with four reporting patient-centred elements in their intervention. CONCLUSIONS: RCT primary outcomes found deprescribing is safe and reduces drug number or dose. Five RCTs found a significant deprescribing impact on HRQOL, cost or hospitalisation. Important future research agendas include analysing (1) understudied outcomes like cost, and (2) intervention and implementation components that enhance effectiveness, such as patient-centred elements.

Clarifying misbeliefs about hydroxychloroquine (HCQ): developing the HCQ benefits versus harm decision aid (HCQ-SAFE) per low health literacy standards.

BACKGROUND: Up to 83% of patients with SLE stop taking hydroxychloroquine (HCQ) within the first year due to knowledge gaps regarding the survival benefits of HCQ versus inflated fears of rare toxicity. Thus, there is a need for a shared decision-making tool that highlights HCQ's significant benefits versus rare harms to improve patients' understanding and align treatments with their values. The objective of this study was to describe development and piloting of a decision aid (HCQ-SAFE) to facilitate HCQ adherence, and safe, effective use by engaging patients in therapeutic decision-making. METHODS: HCQ-SAFE was developed via a collaborative process involving patients, clinicians, implementation scientists and health literacy experts. The initial prototype was informed by Agency for Healthcare Research and Quality (AHRQ) low literacy principles and key themes about HCQ use from six prior patient and clinician focus groups, with iterative expert and stakeholder feedback to deliver a final prototype. We implemented HCQ-SAFE in four clinics to examine usability and feasibility on Likert scales (0-7) and net promoter score (0%-100%). RESULTS: The final HCQ-SAFE shared decision-making laminated tool organises data using pictograms showing how HCQ use reduces risk of organ damage, early death and blood clots versus low risk of eye toxicity.HCQ-SAFE was reviewed in all eligible patient visits (n=40) across four clinics on an average of ~8 min, including 25% non-English-speaking patients. All patients scored 100% on the knowledge post-test; no decisional conflicts were noted after using HCQ-SAFE. HCQ-SAFE garnered high clinician and patient satisfaction with 100% likelihood to recommend to peers. CONCLUSIONS: HCQ-SAFE is a stakeholder-informed feasible shared decision-making tool that enhances communication and can potentially improve knowledge, clarify misbeliefs and engage patients in treatment decisions, including those with limited English proficiency.

Depressive symptoms and reduced preventive care use in older adults: the mediating role of perceived access.

BACKGROUND: Depressive symptomatology is common in older adults and is associated with reduced adherence to recommended preventive care, but little is known as to why. Understanding how depressive symptoms may interfere with adherence can help to identify leverage points for interventions to increase preventive service use. OBJECTIVE: This study examined perceived access to medical care as a possible mediator linking depressive symptomatology to reduced preventive service use in older adults. METHODS: We analyzed data from 5465 respondents completing the 1993 and 2003/2004 waves of the Wisconsin Longitudinal Study. Depressive symptomatology was assessed using the Center for Epidemiologic Studies Depression Scale. Perceived access survey items were organized through factor analysis to represent key dimensions of access: availability/accessibility, affordability, acceptability, and accommodation. The primary outcome was the total number of 7 recommended preventive services that respondents received. Multivariate path analysis was used to estimate direct and indirect effects between depressive symptomatology, perceived access, and preventive service use. RESULTS: Older adults with depressive symptomatology received fewer recommended services. Depressive symptomatology reduced preventive service use by adversely affecting 2 dimensions of perceived access: (1) acceptability, pertaining to poor patient-provider trust and communication, and (2) accommodation, pertaining to inconveniently organized services. CONCLUSIONS: Depressive symptomatology may negatively alter older adults' perceptions of access and, in turn, negatively impact their preventive service use. In addition to treating depression, interventions designed to mitigate the impact of depression on the patient-provider relationship, and organizational changes to practice that better accommodate the needs of depressed patients, may increase adherence to preventive care guidelines in depressed older adults.

Effectiveness of intervention to implement tobacco cessation counseling in community chain pharmacies.

OBJECTIVES: To test the feasibility of implementing ask-advise-refer (AAR) tobacco cessation counseling approach in community chain pharmacies serving low socioeconomic areas and to assess the effectiveness of a multimodal intervention on short-term implementation of AAR. DESIGN: Randomized controlled trial. SETTING: South-central Wisconsin from July 2008 through March 2009. PARTICIPANTS: Pharmacists and technicians from 16 community chain pharmacies. INTERVENTION: Training to implement AAR, workflow integration recommendations, tobacco cessation poster to create awareness, and a support visit. MAIN OUTCOME MEASURES: Number of pharmacy patrons asked about tobacco use, number of tobacco users advised to quit, number of tobacco users enrolled in the quit line, and number of quit line cards given. RESULTS: As hypothesized, the multimodal intervention significantly predicted the number of patrons asked to quit (estimate 4.84, incidence rate ratio 127.2, P < 0.001), number of tobacco users advised to quit (2.12, 8.33, P < 0.01), number of tobacco users enrolled in the quit line (2.31, 10.13, P < 0.001), and number of quit line cards given (1.04, 2.82, P < 0.05). CONCLUSION: This trial demonstrates the feasibility of implementing AAR in routine community pharmacy practice. This trial also supports the short-term effectiveness of the multimodal intervention in facilitating AAR in partnership with other public health systems. More research is needed to evaluate the generalizability, effectiveness, and sustainability of AAR, including factors influencing adoption and the impact on cessation.