Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. OBJECTIVE: The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. DESIGN: A prospective cohort study with an internal comparison group. PARTICIPANTS: IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications. INTERVENTION: IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. MAIN MEASURES: We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. KEY RESULTS: The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. CONCLUSIONS: Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

A longitudinal, collaborative, practice-based learning and improvement model to improve post-discharge heart failure outcomes.

BACKGROUND: Practice-based learning and improvement is one of the Accreditation Council of Graduate Medical Education's core competencies fortrainees. Residencyprograms have grappled with how to accomplish this goal. AIM: We describe our institution's unique, longitudinal post-graduate year process and project. SETTING: West Haven, VA Medical Center. PARTICIPANTS: Yale University School of Medicine junior residents on ambulatory electives and faculty preceptor. PROGRAM DESCRIPTION: Longitudinal program aimed to decrease re-admissions for hospitalized patients with congestive heart failure. DISCUSSION: We feel that our longitudinal project is a novel innovation worthy of further study.

Development and Validation of a Polypharmacy Knowledge Assessment Instrument.

Objective. To develop a brief instrument for academic pharmacists or physicians to use in assessing postgraduate residents' knowledge of polypharmacy. Methods. Five clinicians used a modified Delphi process to create a 26-item multiple-choice test to assess knowledge of polypharmacy in geriatric primary care. The test was distributed to 74 participants: 37 internal medicine (MD) residents, six nurse practitioner (NP) residents, nine primary care attendings, 12 pharmacists and pharmacy residents, and 10 geriatrics attendings and fellows. Construct validity was assessed using factor analysis and item response theory. Overall group differences were examined using a Kruskal-Wallis test, and between group differences were assessed using the Wilcoxon rank sum test. Results. The response rate for the survey was 89%. Factor analysis resulted in a one factor solution. Item response theory modeling yielded a 12-item and six-item test. For the 12-item test, the mean scores of geriatricians and pharmacists (88%) were higher than those of MD and NP residents (58%) and primary care attendings (61%). No differences were found between MD and NP residents and primary care attendings. Findings for the six-item test were similar. Conclusion. Both the 12-item and six-item versions of this polypharmacy test showed acceptable internal consistency and known groups validity and could be used in other academic settings. The similar scores between MD and NP residents and primary care attendings, which were significantly lower than scores for pharmacists and geriatricians, support the need for increased educational interventions.

Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic.

An interprofessional polypharmacy clinic for intensive management of medication regimens helps high-risk patients manage their medications.

Hypokalemia among patients receiving treatment for multidrug-resistant tuberculosis.

INTRODUCTION: Between January 1999 and December 2000, 125 patients in Lima, Peru were enrolled in individualized treatment for multidrug-resistant tuberculosis (MDR-TB). Hypokalemia was observed to be an important adverse effect encountered in this cohort. OBJECTIVE: To identify risk factors associated with the development and persistence of hypokalemia during MDR-TB therapy, and to review the incidence and management of hypokalemia in patients receiving MDR-TB therapy. METHODS: A retrospective case series of 125 patients who received individualized therapy for MDR-TB between January 1, 1999, and December 31, 2000. RESULTS: Among 115 patients who were screened for electrolyte abnormalities, 31.3% had hypokalemia, defined as a potassium level of < 3.5 mEq/L. Mean serum potassium at time of diagnosis was 2.85 mEq/L. Diagnosis of low serum potassium occurred, on average, after 5.1 months of individualized therapy. Multivariate analysis of risk factors for this adverse reaction identified two causes: administration of capreomycin, and low initial body weight. Normalization of potassium levels was achieved in 86% of patients. CONCLUSIONS: Electrolyte disturbance was frequently encountered in our cohort of patients with MDR-TB. Successful screening and management of hypokalemia was facilitated by training the health-care team in the use of a standardized algorithm. Morbidity from hypokalemia can be significant; however, effective management of this side effect is possible without sacrificing MDR-TB treatment efficacy.