Communicating deprescribing decisions made in hospital with general practitioners in the community.

BACKGROUND: Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients. AIMS: To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital. METHODS: Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach. RESULTS: GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long-term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow-up actions were crucial in a discharge summary to enable care post-discharge. CONCLUSIONS: GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process.

Mediation analysis of conspiratorial thinking and anti-expert sentiments on vaccine willingness.

OBJECTIVE: Vaccines are an effective means to reduce the spread of diseases, but they are sometimes met with hesitancy that needs to be understood. METHOD: In this study, we analyzed data from a large, cross-country survey conducted between June and August 2021 in 43 countries (N = 15,740) to investigate the roles of trust in government and science in shaping vaccine attitudes and willingness to be vaccinated. RESULTS: Despite significant variability between countries, we found that both forms of institutional trust were associated with a higher willingness to receive a COVID-19 vaccine. Furthermore, we found that conspiratorial thinking and anti-expert sentiments predicted reduced trust in government and science, respectively, and that trust mediated the relationship between these two constructs and ultimate vaccine attitudes. Although most countries displayed similar relationships between conspiratorial thinking and anti-expert sentiments, trust in government and science, and vaccine attitudes, we identified three countries (Brazil, Honduras, and Russia) that demonstrated significantly altered associations between the examined variables in terms of significant random slopes. CONCLUSIONS: Cross-country differences suggest that local governments' support for COVID-19 prevention policies can influence populations' vaccine attitudes. These findings provide insight for policymakers to develop interventions aiming to increase trust in the institutions involved in the vaccination process. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Deprescribing perceptions and practice reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module.

BACKGROUND: There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing. OBJECTIVES: 1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students. METHODS: A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module. RESULTS: Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions. CONCLUSIONS: Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.

Delivering the right information to the right person at the right time to facilitate deprescribing in hospital: a mixed methods multisite study to inform decision support design in Australia.

OBJECTIVES: To inform the design of electronic decision support (EDS) to facilitate deprescribing in hospitals we set out to (1) explore the current processes of in-hospital medicines review, deprescribing and communication of deprescribing decisions with the patient's general practitioner (GP), (2) identify barriers to undertaking these tasks and (3) determine user preferences for EDS. DESIGN: Multimethod, multisite study comprising observations, semistructured interviews and focus groups. SETTING: General medicine, geriatric medicine and rehabilitation wards at six hospitals in two local health districts in Sydney, Australia and primary care practices in one primary healthcare district in Sydney, Australia. PARTICIPANTS: 149 participants took part in observations, interviews and focus groups, including 69 hospital doctors, 13 nurses, 55 pharmacists and 12 GPs. MAIN OUTCOME MEASURES: Observational data on who was involved in medicines review and deprescribing, when medicines review took place, and what artefacts (eg, forms) were used. Participants reported perceptions of medicines review, polypharmacy and deprescribing and preferences for EDS. RESULTS: Deprescribing, undertaken during medicines review, was typically performed by a junior doctor, following a decision to deprescribe by a senior doctor. Key barriers to deprescribing included a perception that deprescribing was not the responsibility of hospital doctors, a lack of confidence among junior doctors and pharmacists in broaching this topic with senior doctors and a lack of patient engagement in the deprescribing process. In designing EDS, the tools, likely to be used by junior doctors, pharmacists and nurses, should be available throughout the hospitalisation and should comprise non-interruptive evidence-based guidance on why and how to deprescribe. CONCLUSIONS: Deprescribing decisions are complex and influenced by multiple factors. The implementation of EDS alone is unlikely to address all barriers identified. To achieve sustained improvements in monitoring of polypharmacy and subsequent deprescribing, a multifaceted intervention is needed.

Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients.

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.

Rheumatologists fail to advise people with RA to get immunised, which matters if you are under 65: An audit in a New Zealand rheumatology service.

AIM: To assess if yearly-influenza and five-yearly pneumococcal vaccines are recommended to people with rheumatoid arthritis (RA) in a New Zealand rheumatology service in accordance with guidelines and determine patient immunisation status for these respiratory pathogens. METHODS: Retrospective review of electronic health records of all outpatients with RA attending a regional rheumatology centre in New Zealand over a one-month period immediately after the release of the 2015 influenza vaccination. RESULTS: The 232 people with RA in the sample had a mean age of 60.4 years with 59% having RA for more than five years. Documented advice was infrequent (<5%) at the index visit and other clinically relevant time points. Despite this, many patients were immunised. People with RA over 65 years of age were more likely to receive influenza vaccination, however, the vaccination rate was similar to the general population over 65 years of age. CONCLUSIONS: People with RA receive recommended respiratory vaccinations despite infrequent advice for immunisation from rheumatology specialist services. However, immunisation rate in people with RA, particularly those under 65 years, remains suboptimal and multi-level interventions are required to improve this.

In sight, in mind: retailer compliance with legislation on limiting retail tobacco displays.

We investigated retailer compliance with point-of-sale display legislation, using a New Zealand region as a case study. An observational survey was conducted of nonspecialist tobacco retailers in the lower North Island of New Zealand during 2006. Compliance was assessed in relation to store type (dairies, convenience stores, supermarkets, and service stations) and by characteristics of the population of the census area unit in which the store was situated. These characteristics include the level of socioeconomic deprivation and proportions of Maori (indigenous New Zealanders), Pacific Islanders, and children aged less than 19 years. Out of the 288 stores surveyed, 185 (64%) had at least one breach of the point-of-sale regulations. The most common breaches were a failure to display a "Smoking Kills" sign, visibility of tobacco from outside the premises, and displaying tobacco less than 1 m from children's products. Compliance was significantly worse in dairies (small local general stores) and convenience stores. Stores situated in areas in the top quartile for the proportion of children were much more likely to have high levels of noncompliance (> or =3 breaches) and to display tobacco products close to children's products. This study is one of very few to systematically investigate retailer compliance with point-of-sale display regulations for tobacco products. The results suggest that the implementation of legislation to partly limit retail displays of tobacco products can be difficult. A ban on retail displays of tobacco products is likely to be a more effective and enforceable policy.