Involving community pharmacists in interprofessional collaboration in primary care: a systematic review.

BACKGROUND: The World Health Organization supports interprofessional collaboration in primary care. On over the past 20 years, community pharmacists had been taking a growing number of new responsibilities and they are recognized as a core member of collaborative care teams as patient-centered care providers. This systematic review aimed to describe interprofessional collaboration in primary care involving a pharmacist, and its effect on patient related outcomes. METHODS: A systematic review of randomized controlled trials cited in the MEDLINE, EMBASE, PsycInfo and CINAHL in English and French was conducted from inception to November 2022. Studies were included if they described an intervention piloted by a primary care provider and included a pharmacist and if they evaluated the effects of intervention on a disease or on patient related outcomes. The search generated 3494 articles. After duplicates were removed and titles and abstracts screened for inclusion, 344 articles remained. RESULTS: Overall, 19 studies were included in the review and assessed for quality. We found 14 studies describing an exclusive collaboration between physician and pharmacist with for all studies a three-step model of pharmacist intervention: a medication review, an interview with the patient, and recommendations made to physician. Major topics in the articles eligible for inclusion included cardiovascular diseases with blood pressure, diabetes, dyslipidemia, and risk of cardiovascular diseases. Positive effects concerned principally blood pressure. CONCLUSIONS: Collaboration involving pharmacists is mainly described in relation to cardiovascular diseases, for which patient-centered indicators are most often positive. It underscores the need for further controlled studies on pharmacist-involved interprofessional collaboration across various medical conditions to improve consensus on core outcomes measures.

A systematic review of the impact of simulation on students' confidence in performing clinical pharmacy activities.

BACKGROUND: Although confidence does not automatically imply competence, it does provide pharmacy students with a sense of empowerment to manage a pharmacotherapeutic problem independently. Among the methods used in higher education, there is growing interest in simulation. AIM: To evaluate the impact of simulation on pharmacy students' confidence in performing clinical pharmacy activities. METHOD: Articles that reported the use of simulation among pharmacy students with fully described outcomes about confidence were included. Studies for which it was impossible to extract data specific to pharmacy students or simulation were excluded. The search was carried out in Medline, Embase, Lissa and PsycInfo from inception to August the 31th, 2022. The results were synthesized into 4 parts: confidence in collecting information, being an expert in a procedure/pathology, counselling and communicating, and other results. The quality assessment of included studies was conducted using the Mixed Methods Appraisal Tool "MMAT" tool. RESULTS: Among the 39 included articles, the majority were published in the last 5 years and conducted in the United States. The majority included pharmacy students in years 1 through 3 (69.2%). The most common study design was the pre-post uncontrolled design (66.7%). Studies measuring the effects of human and/or virtual simulation were mainly focused on confidence to counsel and/or communicate with patients and colleagues (n = 20). Evaluations of the effects of these types of simulation on confidence in information gathering by health professionals were also well represented (n = 16). CONCLUSION: Simulation-based training generally yielded positive impact on improving pharmacy students' confidence in performing clinical pharmacy activities. Rigorous assessment methods and validated confidence questionnaires should be developed for future studies.

Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study.

Rationale & Objective: Patients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis. Study Design: Prospective controlled quality improvement study with a contemporaneous control. Setting & Participants: Patients prescribed ≥5 medications in 2 outpatient dialysis units in Montréal, Canada. Exposures: Patient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone. Analytical Approach: The proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated. Outcomes: The primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline. Results: In total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8 ± 15.9 (SD), and 36.9% were women. The proportion of patients with ≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P < 0.0001; number needed to treat = 3). Limitations: This was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events. Conclusions: Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.

Patients treated with dialysis are commonly prescribed multiple medications, some of which are potentially inappropriate medications (PIMs). PIMs can increase a patient's pill burden and are associated with an increased risk of harm (some examples include falls, fractures, and hospitalization). Deprescribing is a proposed solution that aims to highlight medications that can be stopped, reduced, or switched to a safer option, under supervision of a health care provider. We aimed to determine if a quality improvement intervention in the dialysis unit could increase deprescribing compared to usual care. The study took place in 2 outpatient hemodialysis units where usual care involves nurses and nephrologists performing medication reviews twice a year. The intervention was a deprescribing report that was generated with the help of a software tool called MedSafer, along with brochures for patients with information on PIMs they were taking. In the intervention unit, we increased the number of patients who had a medication safely deprescribed by 36.6% more than on the control unit. Although the study was small, a future larger study in dialysis patients might show that a computer software such as MedSafer can prevent harmful complications from taking too many medications.

[Implementation of pharmaceutical consultations in digestive oncology in a teaching hospital: one-year outcomes]. / Mise en place de consultations pharmaceutiques d'initiation en oncologie digestive dans un centre hospitalo-universitaire : bilan à un an.

INTRODUCTION: The announcement of a cancer diagnosis is traumatic for the patient. In France, an announcement system has been in place, providing medical time for announcement and treatment proposal, nursing time for support, without including the pharmacist. In order to improve management of patients treated with intravenous anticancer drugs, we set up introductory pharmaceutical consultations in digestive oncology. The aims were to assess the situation one year after the introduction of these consultations, and to assess their contribution. METHODS: When a patient was diagnosed with digestive cancer and receiving intravenous treatment, a pharmaceutical initiation consultation was scheduled. Indicators of activity (number of consultations, average duration, average preparation time and various delays) and results (number and type of pharmaceutical interventions, patient satisfaction) were collected in order to assess activity. RESULTS: Forty-seven pharmaceutical initiation consultations were carried out. The average duration of the consultations was 39.3minutes. Consultations were carried out on average 12.1 days after the medical consultation and 9.6 days before the first chemotherapy treatment. Twenty-nine patients responded to the satisfaction questionnaire. All were satisfied, and the majority of patients said they had improved their knowledge of cancer treatment. DISCUSSION: This activity enables us to review with patients essential aspects of their care, such as implanting an implantable chamber catheter, anti-cancer treatment and managing potential side effects and improve their self-care skills.

Deep continuous sedation at the patient's request until death in a palliative care unit: retrospective study.

OBJECTIVES: Limited descriptive data are available on continuous and deep sedation maintained until death (CDSUD) at the patient's request in palliative care units. This study aimed to describe such practices in the context of refractory suffering or after a request to stop life-sustaining treatment, evaluating the duration and dosage of sedative treatments used. METHODS: This retrospective observational study included consecutively hospitalised patients in a palliative care unit from January 2020 to December 2021. Data on patient profiles, reasons for the sedation request, duration of sedation and doses of sedatives were collected. RESULTS: Among 42 patients who underwent CDSUD, 79% occurred due to refractory suffering. In cases of sedation following a request to stop life support, high-dose corticosteroid therapy was the most commonly involved life-sustaining treatment. Midazolam was always the first-line sedative treatment. Chlorpromazine was added in 79% of cases, and propofol in 40%, to achieve a deep level of sedation. The mean maximum doses of midazolam, chlorpromazine and propofol were 7.6 mg/hour (±1.9), 3.3 mg/hour (±0.9) and 1.7 mg/kg/hour, respectively. The average duration of sedation was 37 hours. CONCLUSIONS: This study provides new descriptive elements on CDSUD. Notably, it highlights the use of second-line sedative molecules, such as propofol.

Exploration of the barriers and enablers of benzodiazepines deprescribing in prisons: A qualitative study among health and social care professionals.

BACKGROUND: The prison environment is a place of high consumption of benzodiazepines (BZDs) due to the anxiety and sleep disturbances, mental disorders, detoxification and trafficking. OBJECTIVE: The study aims to explore experiences of health and social care professionals on the use of BZDs in prisons, as well as the barriers and enablers to their deprescribing. METHOD: Semistructured individual interviews with professionals working in a prison setting were performed between March and April 2022, based on an interview guide. They were recorded and transcribed using the NVivo software. A qualitative analysis using an inductive approach based on a thematic analysis was performed. RESULTS: Sixteen health professionals were interviewed, including psychiatrists, general practitioners, nurses, pharmacists, psychologists, musicologists and pharmacy technicians. The identified barriers to deprescribing BZDs were problems of coordination between prescribers, lack of time and alternatives. Concerning the enablers, therapeutic education groups, staff's awareness of the irrelevance of some medication and multi-professional advice were identified. DISCUSSION: This study highlights the similarities in deprescribing difficulties between prison and other settings. Some of the levers identified in our study have shown their effectiveness in different settings. CONCLUSION: Deprescribing is done most of the time in good conditions but requires an additional delay compared to the outside environment.

Multi-professional development of a competency framework for patients with a Port-a-Cath (PAC).

PURPOSE: In France, 40,000 Port-a-Cath (PAC) are inserted each year. These medical devices are prone to complications during their insertion or use. The education of patients wearing these devices could be a lever to reduce the risk of complications. The objective of this work was to develop, in a multi-professional and consensual manner, a unique and specific skills reference framework for patients with PAC and to propose it as a reference tool for health professionals. METHODS: A multidisciplinary working group was set up to draw up this reference framework of skills. The first stage of the work consisted of a reflection leading to an exhaustive list of competencies necessary for the patient. These skills were then classified according to three different fields of knowledge (theoretical, know-how and attitudes). Finally, the working group identified priority competencies and established a grid that can be used to evaluate the level of acquisition of these competencies. RESULTS: Fifteen competencies were identified: five relating to theoretical knowledge, six relating to know-how and four relating to attitudes. These competencies were broken down into sub-competences. Seven competencies or sub-competencies were selected to constitute the list of priority competencies. DISCUSSION: This competency framework provides a reference framework for the education of patients with PAC and will help to harmonise practices within the different teams that care for patients with PAC.

Are the deprescribing guidelines for proton pump inhibitors in palliative care applicable? A monocentric observational study.

OBJECTIVES: Proton pump inhibitors (PPIs) are among the most commonly prescribed medications. The aim of this study was to assess the appropriateness of prescribing PPIs in the palliative care unit on admission and during hospitalisation to determine the applicability of deprescribing recommendations. METHODS: A monocentric observational study was conducted over a 6-month period in 2020 in a university palliative care unit. Data on indication, starting date, dose and posology were collected at discharge from the medical record and by contacting the prescriber. A physician and a pharmacist evaluated PPI prescription appropriateness according to guidelines. RESULTS: 131 patients (mean age: 69.5 years; 82% with cancer) were included. Prior to admission, 41% (54/131) of patients were already prescribed PPIs. During hospitalisation, 50% of prescriptions were discontinued, while 12% were initiated. The indication was known for 50% of patients on admission and 59% during their stay. Among patients with PPI prescriptions, 56% had a relevant indication on admission, and 63% during their stay. The prevalence of potential drug interactions was low (<1/10). CONCLUSIONS: While PPIs remain essential for specific indications, this study highlights their excessive prescription even during palliative care. Implementing deprescribing recommendations in this population is crucial to optimise treatment plans.

Observational and prospective study: evaluation of beliefs and representations of chronic treatments of polymedicated patients hospitalised in a vascular medicine and surgery department.

OBJECTIVES: Today, the involvement of patients in their care is essential. As the population ages increases, the number of patients with chronic diseases is increasing. In the vascular medicine and surgery departments, patients are polymedicated and mostly suffer from several chronic diseases. Approximately 50% of patients with a chronic disease are not adherent. Among the factors that can influence therapeutic adherence are the beliefs and representations of patients.To evaluate the beliefs and representations of chronic treatments in patients with multiple medications and hospitalised in a vascular medicine and surgery department, and to evaluate the medication adherence, the knowledge and the importance patients attach to their treatments. DESIGN: Observational, prospective and a single-centre study. SETTING: The study was conducted in a French tertiary hospital centre of around 3000 beds in 9 institutions. PARTICIPANTS: Adult polymedicated (ie, minimum of five chronic treatments) patients hospitalised in a vascular medicine and surgery department were included after application of the exclusion criteria. METHODS: Patient interviews were carried out in the department and were based on three interviewer-administered questionnaires (a global questionnaire, the Belief Medical Questionnaire and the GIRERD questionnaire). RESULTS: Our study showed that patients perceived their treatments as beneficial rather than worrying. A correlation between medication adherence and beliefs was observed. 'Non-adherent'patients had a more negative overall view of medication than 'adherent' patients. The level of compliance and knowledge of our patients was low. Only 11% of the patients were 'good adherent', 16% of the patients could perfectly name their treatment and 36% knew all the indications. CONCLUSION: Knowledge of treatment representation and beliefs are central to understanding patient behaviour. Considering patients' representations will allow the identification of levers, and the development of actions and educational tools adapted to improve their adherence, their knowledge and therefore their drug management.

Evaluation of the impact of pharmacist-led educational intervention on knowledge and skills of cancer patients with totally implantable venous access port: a single-centre, non-randomised controlled study.

BACKGROUND: Totally implantable venous access port (TIVAP) is a type of implantable medical device that enables repetitive access to the intravenous system through use of a Huber needle. This device facilitates the administration of aggressive or long-term treatments while ensuring the comfort and safety of the patient. To ensure proper use of the medical device and lower the risk of complications, it is essential that patients acquire the necessary knowledge and skills regarding TIVAP. OBJECTIVE: The main objective of the study was to assess the impact of a pharmaceutical interview on patients' knowledge and skills for patients with TIVAP. METHODS: To achieve this goal, a pharmaceutical interview guide and an 18-item questionnaire were developed, based on a three-part competency framework (knowledge, know-how and attitudes) previously constructed by a multidisciplinary team. The intervention consisted of a pharmacist-led interview with every patient on the day of the TIVAP insertion. Patients in the control group received usual care. Patients included were interviewed by telephone 14 days after implantation. χ2 tests were conducted to compare the scores obtained by each group. RESULTS: The average score obtained by the control group (n=30) was 8.97, while the intervention group (n=59) achieved an average score of 12.66 (p<0.001). The intervention group demonstrated increases in correct responses for all items, with eight questions displaying significantly higher scores. Six of these pertained to theoretical knowledge, one to know-how and one to attitudes. CONCLUSION: The interviews had a clear impact on the knowledge and skills of TIVAP patients.

Factors influencing French community pharmacists' willingness to participate in research projects: a mixed method study.

BACKGROUND: French community pharmacists are facing an increasing demand to provide a wider range of services to meet the needs of the population. These new missions must be evaluated by primary care research studies. This study aims to explore the factors that influence French community pharmacists' willingness to participate in research projects. METHODS: A mixed-method design was adopted for this study, comprising an initial quantitative online survey followed by semi-directed interviews. The investigation was conducted at two French faculties of pharmacy, Angers and Nantes, involving students in their 6th and final year of pharmacy education, and their community pharmacist tutors. The survey items were based on a study by Saini et al. and participants responded using five-point Likert scales. The semi-directed interviews were conducted after the quantitative analysis, only with volunteer and already graduated community pharmacists. RESULTS: A total of 131 people participated in the quantitative analysis, comprising 75 students and 56 pharmacists. Pharmacists and students agreed on the significance of two key aspects: the research must possess a clear and meaningful purpose, and researchers must keep the pharmacists informed about the study's results. Among the 27 proposed items, only three showed significantly different results between students and pharmacists. Moreover, 11 semi-structured interviews were conducted. Research in the community pharmacy domain is relatively new for many pharmacists. Despite limited training, their willingness to participate is contingent on being actively involved from the outset, receiving appropriate support and training. However, the research should be seamlessly integrated into their daily practice, without being too time-consuming and administratively burdensome. Time constraints emerged as the main obstacle, along with concerns about the availability of human resources. Pharmacists expressed strong motivation driven by the research topic's relevance, and its potential impact on patients or the profession. While financial compensation is desirable, it did not appear to be the main criterion for participation in a study. CONCLUSIONS: French pharmacists are willing to participate in research projects to improve patient care and develop the profession. Research teams must guide and involve from the project's inception.

Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review.

BACKGROUND: In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes. METHODS: We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist. RESULTS: Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders. CONCLUSIONS: Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial.

Background: Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults. Methods: This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires. Discussion: This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways. Clinical trial registration: ClinicalTrials.gov, identifier, NCT05765656.

The experience of being a caregiver of patients with digestive cancer, from patients and caregivers' perception: A mixed study.

BACKGROUNDS: Caregivers are essential in the care of a patient with digestive cancer. Considering their experience and needs is crucial. OBJECTIVES: To explore the experience of caregivers of patients with digestive cancer and to compare the perspectives of patients and caregivers. METHODS: A mixed-methods study with a cross-sectional prospective and a comprehensive qualitative dimension was performed in a medical oncology unit in a French tertiary hospital. Dyads made of patients with digestive cancer and their caregiver were recruited. The Caregiver Reaction Assessment (CRA) and the Supportive Care Needs Survey for Partners and Caregivers (SCNS-PC) questionnaires were distributed to caregivers. The CRA was used to measure the caregiver burden and the SCNS-PC was used to identify the unmet supportive care needs of caregivers. Semi-structured interviews with the dyads were conducted. Qualitative interviews addressed various dimensions of the caregiver's experience from each dyad's member perspective. RESULTS: Thirty-two caregivers completed the questionnaires. Responses showed high self-esteem, schedule burden, and a need for care and information services. Ten dyads participated in the interviews. Three themes emerged from the caregiver's interviews: illness is an upheaval; loneliness and helplessness are experienced; caring is a natural role with positive outcomes. Four themes emerged from patient's interviews: the caregiver naturally assumes the role and gets closer; he is the patient's anchor; his life is disrupted; anxiety and guilt accompany the desire to protect him. In comparing patient and caregiver data, the main theme of disagreement was their relationship. CONCLUSIONS: Caregiver care does not appear to be optimal, particularly in terms of their need for information. Patients have a fairly good representation of their experience, but the caregivers' opinion need to be considered.

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study.

Background: Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Objectives: Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. Design: This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. Setting: The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. Patients: A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. Measurements: We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. Methods: The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Limitations: Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Conclusions: Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. Trial registration: This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.

Contexte: Les patients sous dialyse se voient souvent prescrire de nombreux médicaments (polypharmacie), dont plusieurs médicaments potentiellement inappropriés (MPI). Les MPI sont associés à un risque accru de chutes, de fractures et d'hospitalisations. MedSécure est un outil électronique qui génère des rapports individualisés et classés par ordre de priorité indiquant les possibilités de déprescription. L'outil fonctionne en croisant les données sur la santé des patients et les médicaments sous ordonnance avec des lignes directrices pour la déprescription. Objectifs de l'étude: L'objectif principal est de favoriser la déprescription par rapport aux soins habituels (Medication Reconciliation [MedRecs] ou bilan comparatif des médicaments) chez les patients ambulatoires recevant une hémodialyse d'entretien, en fournissant des rapports MedSécure de déprescription à l'équipe soignante et des brochures encourageant la déprescription aux patients. Conception: Cette étude prospective et contrôlée (témoin contemporain) d'amélioration de la qualité s'appuie sur la politique existante dans les centers d'hémodialyse ambulatoires où un bilan des médicaments (MedRecs) est effectué deux fois par année par le néphrologue traitant et l'équipe de soins infirmiers. Cadre: L'étude a lieu dans deux des trois unités d'hémodialyse ambulatoire du Center universitaire de santé McGill à Montréal (Québec, Canada). L'unité d'intervention est l'Hôpital de Lachine et l'unité témoin est l'Hôpital général de Montréal. Sujets: Une cohorte fermée de patients ambulatoires sous hémodialyse qui visitent plusieurs fois par semaine un center d'hémodialyse pour leurs traitements. La cohorte initiale de l'unité d'intervention compte 85 patients, tandis que l'unité témoin compte 132 patients. Seront exclus les patients qui recevront une greffe, qui seront hospitalisés pendant leur MedRecs ou qui décèderont avant ou pendant le MedRecs. Mesures: Nous comparerons les taux de déprescription entre les unités témoin et d'intervention après un seul MedRecs. Dans l'unité d'intervention, le MedRecs sera associé aux rapports MedSécure (l'intervention); dans l'unité témoin, le MedRecs aura lieu sans rapports MedSécure (soins habituels). Au sein de l'unité d'intervention, les patients recevront également des brochures encourageant la déprescription pour certaines classes de médicaments (gabapentinoïdes, inhibiteurs de la pompe à protons, hypnotiques sédatifs et opioïdes pour les douleurs chroniques non cancéreuses). Les médecins de l'unité d'intervention seront interviewés après le MedRec pour déterminer les obstacles et les facilitateurs à la mise en œuvre. Méthodologie: Le principal critère d'évaluation sera la proportion de patients dans l'unité d'intervention chez qui au moins un MPI sera déprescrit après un MedRec semestriel, par rapport à l'unité témoin. L'étude s'appuiera sur les politiques existantes visant à optimiser la médication chez les patients suivant des traitements d'hémodialyse d'entretien. L'outil électronique d'aide à la décision de déprescription MedSécure sera testé en contexte de dialyse, où les néphrologues sont régulièrement en contact avec les patients. Les MedRecs sont une activité clinique interdisciplinaire effectuée semestriellement sur les unités d'hémodialyse (au printemps et à l'automne) et dans la semaine suivant un congé de l'hôpital. Cette étude aura lieu à l'automne 2022. Des entretiens semi-structurés seront menés avec les médecins de l'unité d'intervention afin d'établir les obstacles et les facilitateurs à la mise en œuvre du processus MedRec complété par MedSécure, puis analysés selon une théorie fondée sur la recherche qualitative. Limites: La déprescription peut être limitée par des contraintes de temps des néphrologues, des troubles cognitifs résultant des maladies et des régimes médicamenteux complexes des patients sous hémodialyse ou par un manque de ressources pour éduquer les patients sur les médicaments qu'ils prennent et leurs méfaits potentiels. Conclusion: Un outil électronique d'aide à la décision peut faciliter le processus de déprescription pour l'équipe clinique en fournissant un rappel, en réduisant le temps nécessaire à l'examen et à l'application des recommandations, et en limitant les obstacles liés au moment et à la façon de réduire le nombre de médicaments. Des lignes directrices sur la déprescription dans la population des patients sous dialyse ont récemment été publiées et incorporées au logiciel MedSécure. À notre connaissance, il s'agit de la première étude à examiner l'efficacité du couplage des lignes directrices avec le MedRecs en tirant parti de l'outil électronique d'aide à la décision en contexte d'hémodialyse ambulatoire.

A comparative study of three-dimensional cone-beam CT sialography and MR sialography for the detection of non-tumorous salivary pathologies.

BACKGROUND: Imaging of the salivary ductal system is relevant prior to an endoscopic or a surgical procedure. Various imaging modalities can be used for this purpose. The aim of this study was to compare the diagnostic capability of three-dimensional (3D)-cone-beam computed tomography (CBCT) sialography versus magnetic resonance (MR) sialography in non-tumorous salivary pathologies. METHODS: This prospective, monocenter, pilot study compared both imaging modalities in 46 patients (mean age 50.1 ± 14.9 years) referred for salivary symptoms. The analyses were performed by two independent radiologists and referred to identification of a salivary disease including sialolithiasis, stenosis, or dilatation (primary endpoint). The location and size of an abnormality, the last branch of division of the salivary duct that can be visualized, potential complications, and exposure parameters were also collected (secondary endpoints). RESULTS: Salivary symptoms involved both the submandibular (60.9%) and parotid (39.1%) glands. Sialolithiasis, dilatations, and stenosis were observed in 24, 25, and 9 patients, respectively, with no statistical differences observed between the two imaging modalities in terms of lesion identification (p1 = 0.66, p2 = 0.63, and p3 = 0.24, respectively). The inter-observer agreement was perfect (> 0.90) for lesion identification. MR sialography outperformed 3D-CBCT sialography for visualization of salivary stones and dilatations, as evidenced by higher positive percent agreement (sensitivity) of 0.90 [95% CI 0.70-0.98] vs. 0.82 [95% CI 0.61-0.93], and 0.84 [95% CI 0.62-0.94] vs. 0.70 [95% CI 0.49-0.84], respectively. For the identification of stenosis, the same low positive percent agreement was obtained with both procedures (0.20 [95% CI 0.01-0.62]). There was a good concordance for the location of a stone (Kappa coefficient of 0.62). Catheterization failure was observed in two patients by 3D-CBCT sialography. CONCLUSIONS: Both imaging procedures warrant being part of the diagnostic arsenal of non-tumorous salivary pathologies. However, MR sialography may be more effective than 3D-CBCT sialography for the identification of sialolithiasis and ductal dilatations. TRIAL REGISTRATION: NCT02883140.

Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review.

BACKGROUND: Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS: We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS: Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS: This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.

Patients' preferences in therapeutic decision-making in digestive oncology: a single centre cross-sectional observational study.

Considering the preferences in Shared Decision Making (SDM) of patients with Digestive Cancer (DC) is crucial to ensure the quality of care. To date, there is limited information on preferences in SDM of patients with DC. The objectives of this study were to describe digestive cancer patients' preference for involvement in therapeutic decision-making and to identify variables associated with these preferences. An observational prospective study in a French university cancer center has been conducted. Patients completed two questionnaires to qualify and quantify their preference for involvement in therapeutic decision-making: the Control Preference Scale (CPS) and the Autonomy Preference Index (API), which is composed of the Decision Making (DM) score and the Information Seeking (IS) score. Associations between these scores and socio-demographic data, disease-related data, coping strategies (Brief-COPE), physical (QLQ-C30) and psychological (HADS) quality of life were tested. One-hundred fifteen patients returned the questionnaires. The majority of patients reported a passive (49.1%) or a collaborative (43.0%) CPS status. The mean DM score was 39.4 Variables associated with decision-making preferences were occupational status and time since diagnosis. The identification of variables associated with patients' preferences for involvement in decision-making can help make clinicians aware of patients' needs and wishes. However, it can only be determined by interviewing the patient individually.

Physicians' views on pharmacists' involvement in hospital deprescribing: A qualitative study on proton pump inhibitors.

BACKGROUND: Clinical pharmacists have a pivotal role in the management of the patient's medication. However, it is necessary to know how pharmacist-mediated deprescribing could be implemented in a hospital setting according to hospital physicians. OBJECTIVE: To explore physicians' views on the involvement of hospital pharmacists in the deprescribing process using the example of PPIs. METHODS: A qualitative study using two focus groups with hospital physicians was conducted to determine their attitudes regarding deprescribing initiated by the hospital pharmacist. The interviews were recorded and transcribed using the NVivo analysis software. A thematic analysis led to a categorization of all the verbatims. RESULTS: Hospital doctors are reluctant to deprescribe drugs initiated by a colleague and feel that it is the responsibility of the general practitioner (GP), who fails to do so due to lack of time. In this situation, the hospital pharmacist is in the best position to deprescribe because of his/her expertise in drug therapy. This should be a discussion between the hospital pharmacist, the hospital doctor, the GP and the patient. Deprescribing should always be adapted to the patient's context. CONCLUSION: Hospital physicians are open to a pharmacist-mediated, patient-centred approach to deprescribing as long as the GP is involved.

Psychotropic drugs consumption during 2020 COVID-19 pandemic and lockdowns: Evidence of a surprising resilience of the drugs delivery system in France.

The COVID-19 pandemic imposed two lockdowns of eight and six weeks in France. While access to care was reduced during lockdown periods, these stressful situations with the pandemic and lockdown periods may have a negative impact on mental health, especially in vulnerable subgroups. Monitoring of psychotropic drugs consumption in France is a comprehensive and reliable tool for indirectly analyzing the mental health of French people. This historical cohort study (n = 767 147) investigated the short-term and long-term evolution of the weekly trend of psychotropic drugs users in 2020 by performing a Seasonal Trend decomposition time series analysis. Rate of progression of consumers per week increased from 186 in the last week of 2019 to 261 per week in the last week of 2020 (+40.3%). Our results did not show a significant break in psychotropic drugs consumption trends during the year 2020 and its two lockdowns. The increase in trend regarding psychotropic drugs consumptions was greatest in young people (<15 years) and patients not being socially deprived. Despite the increase in consumers with restrictive health measures, the French drugs delivery system has been able to adapt with the support of government and pharmacy network. This point should be kept in mind as the necessary reforms to the health care system are undertaken. The COVID-19 pandemic has a negative impact on mental health and two lockdowns occurred in France with reduced access to care. In this context, monitoring of psychotropic drugs consumption is a comprehensive and reliable tool for analyzing the mental health of French people. We hypothesized that the psychotropic drugs consumption has increased during the 2020 COVID-19 pandemic, testifying to French people mental health deterioration, with psychotropic drugs consumption breaks during lockdowns, especially during the first "grand national lockdown", due to the closure or difficulties for accessing to health care structures. By carrying out a historical cohort study among Pays de la Loire residents (n = 767 147), we investigated evolution of the weekly trend of psychotropic drugs users in 2020 compared to 2019 by performing a Seasonal Trend decomposition time series analysis. Between 2019 to 2020, we found a + 40.3% rate of progression of consumers per week. During the year 2020, changes in trend regarding psychotropic drugs consumptions was observed in various sub-groups, e.g. greater in the youngest (< 15 years), which may indicate a vulnerable group strongly impacted by COVID-19 negative consequences, and patients not being socially deprived, which may indicate a group with probably an easier access to care. Lockdown periods were not associated with a significant change in psychotropic drug use, suggesting a form of resilience in the French health care system to maintain its capacity to deliver psychotropic treatments. We mainly discussed that despite the increase in consumers and the policies of restricting access to care during lockdown periods, the French drugs delivery system has been able to adapt thanks to supportive policy actions (extension of the prescriptions validity without the need for a renewal by a physician during periods of lockdowns), an efficient pharmacy network with a collaborative practice of health actors that need to be developed and/or conserved to face potential future health crises.