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2.
Eur Geriatr Med ; 2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33835427

RESUMO

PURPOSE: To describe the objectives, methods and expected impact of an international consortium (iKASCADE) whose purpose is to improve drug safety for older adults by addressing prescribing cascades through a sex and gender lens. METHODS: To create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the consortium has created a modified Delphi procedure where international experts in prescribing and managing pharmacotherapy for older adults will rank a list of prescribing cascades as to their clinical importance. We will use administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex internationally, in the hospital, long-term care and community settings. Finally, we will use semi-structured interviews and realistic, country-specific vignettes, each incorporating a prescribing cascade with identified sex differences, to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades. RESULTS: The consortium will synthesize the quantitative and qualitative results to produce a position paper and products-aimed at knowledge users within and outside of academia-designed to elevate the importance of integrating a gender dimension in the identification and prevention of prescribing cascades. CONCLUSION: Findings will improve our understanding of how adverse drug events are different between older women and men and inform the development and dissemination of tailored knowledge translation products to reduce the frequency and impact of prescribing cascades.

3.
BMJ Open ; 11(4): e044517, 2021 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-33811054

RESUMO

OBJECTIVE: Physical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness. DESIGN: Online cross-sectional survey between 6 May and 19 May 2020. SETTING: Ontario, Canada. PARTICIPANTS: Convenience sample of members of a national retired educators' organisation. PRIMARY OUTCOME MEASURES: Self-reported loneliness, including differences between women and men. RESULTS: 4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65-79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03). CONCLUSIONS: While many older adults reported feeling lonely during COVID-19, several characteristics-such as being female and living alone-increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness.


Assuntos
/psicologia , Solidão , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Ontário/epidemiologia , Pandemias
4.
CMAJ ; 193(16): E589, 2021 Apr 19.
Artigo em Francês | MEDLINE | ID: mdl-33875469
5.
Mil Med ; 2021 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-33904931

RESUMO

BACKGROUND: There are no data on the impact of COVID-19 and associated public health measures, including sheltering at home, travel restrictions, and changes in health care provision, on the mental health of older veterans. This information is necessary for government and philanthropic agencies to tailor mental health supports, services, and resources for veterans in the peri- and post-pandemic periods. The objective of this study was to compare mental health symptoms between Canadian Armed Forces (CAFs) veterans and the general Canadian older adult population in the early months of the COVID-19 pandemic. MATERIALS AND METHODS: This was a secondary analysis of a cross-sectional study of older adults in the national Canadian COVID-19 Coping Study. Individuals aged 55 years and older were eligible. A convenience sample of older adults was recruited through a web-based survey administered between May 01, 2020 and June 30, 2020. Canadian Armed Force military service history status (yes/no) was ascertained. The eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the three-item Loneliness Scale were used to measure mental health symptoms. Multivariable logistic regression compared the odds of screening positive for depression, anxiety, and loneliness between veterans and non-veterans. RESULTS: Of 1,541 respondents who answered the final question (87% survey completeness rate), 210 were veterans. Forty percent of veterans met criteria for at least one of the mental health diagnoses compared to 46% of non-veterans (P = .12). The odds of reporting elevated symptoms of depression, anxiety, and loneliness were similar for veteran and non-veteran respondents after adjusting for confounders. CONCLUSION: Veterans' report of mental health symptoms was similar to the general population Spring 2020 of the COVID-19 pandemic. Although veterans' military training may better prepare them to adapt in the face of a pandemic, additional research is needed to understand the longitudinal impacts on physical and mental health.

7.
J Am Geriatr Soc ; 69(5): 1147-1154, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33738789

RESUMO

BACKGROUND/OBJECTIVES: Differences in older adults' worry, attitudes, and mental health between high-income countries with diverging pandemic responses are largely unknown. We compared COVID-19 worry, attitudes towards governmental responses, and self-reported mental health symptoms among adults aged ≥55 in the United States and Canada early in the COVID-19 pandemic. DESIGN: Online cross-sectional survey administered between April 2nd and May 31st in the United States and between May 1st and June 30th, 2020 in Canada. SETTING: Nationally in the United States and Canada. PARTICIPANTS: Convenience sample of older adults aged ≥55. MEASUREMENTS: Likert-type scales measured COVID-19 worry and attitudes towards government support. Three standardized scales assessed mental health symptoms: the eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the three-item UCLA loneliness scale. RESULTS: There were 4453 U.S. respondents (71.7% women; mean age 67.5) and 1549 Canadian (67.6% women; mean age 69.3). More U.S. respondents (71%) were moderately or extremely worried about the pandemic, compared to 52% in Canada. Just 20% of U.S. respondents agreed or strongly agreed that the federal government cared about older adults in their COVID-19 pandemic response, compared to nearly two-thirds of Canadians (63%). U.S. respondents were more likely to report elevated depressive and anxiety symptoms compared to Canadians; 34.2% (32.8-35.6) versus 25.6% (23.3-27.8) for depressive and 30.8% (29.5-32.2) versus 23.7% (21.6-25.9) for anxiety symptoms. The proportion of United States and Canadian respondents who reported loneliness was similar. A greater proportion of women compared to men reported symptoms of depression and anxiety across all age groups in both countries. CONCLUSION: U.S. older adults felt less supported by their federal government and had elevated depressive and anxiety symptoms compared to older adults in Canada during early months of the COVID-19 pandemic. Public health messaging from governments should be clear, consistent, and incorporate support for mental health.

8.
Artigo em Inglês | MEDLINE | ID: mdl-33715299

RESUMO

PURPOSE: Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans. METHODS: We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry. RESULTS: There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade). CONCLUSIONS: We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.

9.
CMAJ ; 193(6): E215, 2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33558408
10.
J Cutan Med Surg ; : 1203475421993770, 2021 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-33566683

RESUMO

BACKGROUND: Psoriasis and atopic dermatitis are common among older adults (≥65 years old), but clinical trials often exclude that population. OBJECTIVE: To synthesize evidence from observational studies on the safety of systemic therapies (conventional or biologic) for psoriasis and atopic dermatitis among older adults in a systematic review. METHODS: We searched MEDLINE and EMBASE (inception to October 31, 2019) and included observational studies reporting adverse events among older people treated with systemic therapy for psoriasis or atopic dermatitis. Outcomes were death, hospitalization, emergency department visits, infections, major cardiovascular events, renal toxicity, hepatotoxicity, and cytopenias. We assessed study quality using the Newcastle-Ottawa Scale. RESULTS: We included 22 studies on treatment for psoriasis and 2 for atopic dermatitis. Most studies were small and non-comparative and 20 of 24 were low quality. Studies comparing safety between medications or medication classes or between older and younger adults did not show apparent differences but had wide confidence intervals around relative effect estimates. Heterogeneity of study design and reporting precluded quantitative synthesis. CONCLUSIONS: There is scant evidence on the safety of conventional systemic and biologic medications for older adults with psoriasis or atopic dermatitis; older adults and their clinicians should be aware of this evidence gap.

11.
J Am Geriatr Soc ; 69(5): 1328-1333, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33432578

RESUMO

OBJECTIVES: Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease. SETTING: Two large administrative claims databases in the United States. PARTICIPANTS: We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days. RESULTS: There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%). CONCLUSION: We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.

12.
Diabetologia ; 64(5): 1093-1102, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33491105

RESUMO

AIMS/HYPOTHESIS: More than 25% of older adults (age ≥75 years) have diabetes and may be at risk of adverse events related to treatment. The aim of this study was to assess the prevalence of intensive glycaemic control in this group, potential overtreatment among older adults and the impact of overtreatment on the risk of serious events. METHODS: We conducted a retrospective, population-based cohort study of community-dwelling older adults in Ontario using administrative data. Participants were ≥75 years of age with diagnosed diabetes treated with at least one anti-hyperglycaemic agent between 2014 and 2015. Individuals were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54-69 mmol/mol [7.1-8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. We measured the composite risk of emergency department visits, hospitalisations, or death within 30 days of reaching intensive glycaemic control with high-risk agents. RESULTS: Among 108,620 older adults with diagnosed diabetes in Ontario, the mean (± SD) age was 80.6 (±4.5) years, 49.7% were female, and mean (± SD) diabetes duration was 13.7 (±6.3) years. Overall, 61% of individuals were treated to intensive glycaemic control and 21.6% were treated to intensive control using high-risk agents. Using inverse probability treatment weighting with propensity scores, intensive control with high-risk agents was associated with nearly 50% increased risk of the composite outcome compared with conservative glycaemic control with low-risk agents (RR 1.49, 95% CI 1.08, 2.05). CONCLUSIONS/INTERPRETATION: Our findings underscore the need to re-evaluate glycaemic targets in older adults and to reconsider the use of anti-hyperglycaemic medications that may lead to hypoglycaemia, especially in setting of intensive glycaemic control.

13.
Lancet ; 397(10268): 21, 2021 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-33333004
15.
Healthc Policy ; 16(2): 69-81, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33337315

RESUMO

BACKGROUND: Retirement home residents represent a growing proportion of older Ontarians who cannot be identified within existing administrative databases. OBJECTIVE: This article aims to develop an approach for determining, from an individual's postal code, their likelihood of residing in a retirement home. METHODS: We identified 748 licensed retirement homes in Ontario as of June 1, 2018, from a public registry. We developed a two-step evaluation and verification process to determine the probability (certain, likely or unlikely) of identifying a retirement home, as opposed to other dwellings, within a postal code. RESULTS: We identified 274 (36.7%) retirement homes within a postal code certain to indicate that a person was residing in a retirement home, 200 (26.7%) for which it was likely and 274 (36.7%) for which it was unlikely. Postal codes that were certain and likely identified retirement homes with a capacity for 59,920 residents (79.9% of total provincial retirement home capacity). CONCLUSION: It is feasible to identify a substantive cohort of retirement home residents using postal code data in settings where street address is unavailable for linkage to administrative databases.

16.
Ther Adv Drug Saf ; 11: 2042098620968310, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33240479

RESUMO

Introduction: Prescribing cascades occur when the side effect of a drug is misinterpreted as a new medical condition, and a second drug is prescribed to address the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades due to greater multimorbidity, polypharmacy, and complexity of care. The objective of this study was to evaluate educational materials about prescribing cascades in persons with AD, and elicit input on their use in a future trial. Methods: We interviewed community-dwelling adults with either an AD diagnosis or a prescription drug used to treat AD (n = 12), caregivers of patients meeting the same criteria (n = 14), and providers (n = 15). We coded interview transcripts and organized themes according to the communication-human information processing model. We revised the materials based on the interviews, and surveyed participating caregivers and providers for their reactions to the revised materials. Results: Analysis of patients', caregivers', and providers' comments suggest: (a) Providers had conflicting views about the messaging of materials; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patient/caregiver-initiated conversations; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried that mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect the clinical encounter; (g) Participants felt that materials would improve patient/caregiver engagement. When surveyed, most providers found the revised materials informative and actionable, and most caregivers found them understandable and useful. Conclusions: This evaluation of educational materials about prescribing cascades in patients with AD provides strong support for engaging caregivers to communicate with providers about prescribing cascades. By giving patients and caregivers a basic description of the prescribing cascade concept, our educational materials may help them prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future trial. Lay summary: Patient, caregiver and provider thoughts on educational materials about prescribing and medication safety Prescribing cascades occur when the side effect of a medication is misinterpreted as a new medical condition, and a second medication is prescribed to treat the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades because they often have more medical conditions, more medications, and more complex care. The goal of this study was to evaluate mailed educational materials about prescribing cascades in persons with AD, and get input on their use in a future study. We interviewed 12 adults with AD, or prescribed a medication to treat AD, 14 caregivers of persons with AD, and 15 providers. We reviewed the interview transcripts to identify important findings about our educational materials. We edited the materials based on the interviews, and sent participating caregivers and providers a questionnaire to get their reactions to the new materials. Important findings from the interviews suggest: (a) Providers had conflicting views about the recommendations given; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patients/caregivers introducing the topic; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect a doctor's appointment; (g) Participants felt strongly that materials would improve patient/caregiver engagement. When surveyed, almost all providers found the revised materials informative and actionable; and most caregivers found them understandable and useful. These findings provide strong support for engaging caregivers to communicate with providers about prescribing cascades. The educational materials may help patients and caregivers prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future study.

17.
Thorax ; 2020 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-32999059

RESUMO

INTRODUCTION: Respiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD). METHODS: This was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used. RESULTS: Rate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61-1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14-2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17-7.09) and all-cause mortality (HR 3.31; 95% CI 1.30-9.51). CONCLUSIONS: New cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.

18.
Am Heart J ; 232: 47-56, 2020 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-33022231

RESUMO

Contemporary data on the effect of levothyroxine dose on the occurrence of atrial fibrillation (AF) are lacking, particularly in the older population. Our objective was to determine the effect of cumulative levothyroxine exposure on risk of AF and ischemic stroke in older adults. METHODS: We conducted a population-based observational study using health care databases from Ontario, Canada. We identified adults aged ≥66 years without a history of AF who filled at least 1 levothyroxine prescription between April 1, 2007, and March 31, 2016. Cases were defined as cohort members who had incident AF (emergency room visit or hospitalization) between the date of first levothyroxine prescription and December 31, 2017. Index date was date of AF. Cases were matched with up to 5 controls without AF on the same index date. Secondary outcome was ischemic stroke. Cumulative levothyroxine exposure was estimated based on total milligrams of levothyroxine dispensed in the year prior to index date. Using nested case-control approach, we compared outcomes between older adults who received high (≥0.125 mg/d), medium (0.075-0.125 mg/d), or low (0-0.075 mg/d) cumulative levothyroxine dose. We compared outcomes between current, recent past, and remote past levothyroxine use. RESULTS: Of 183,360 older adults treated with levothyroxine (mean age 82 years; 72% women), 30,560 (16.1%) had an episode of AF. Compared to low levothyroxine exposure, high and medium exposure was associated with significantly increased risk of AF after adjustment for covariates (adjusted odds ratio [aOR] 1.29, 95% CI 1.23-1.35; aOR 1.08, 95% CI 1.04-1.11; respectively). No association was observed between levothyroxine exposure and ischemic stroke. Compared with current levothyroxine use, older adults with remote levothyroxine use had lower risks of AF (aOR 0.56, 95% CI 0.52-0.59) and ischemic stroke (aOR 0.61, 95% CI 0.56-0.67). CONCLUSIONS: Among older persons treated with levothyroxine, levothyroxine at doses >0.075 mg/d is associated with an increased risk of AF compared to lower exposure.

19.
J Am Geriatr Soc ; 2020 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-33025584

RESUMO

BACKGROUND/OBJECTIVES: Cognitive changes are commonly observed in older adults following surgical procedures. There are concerns that exposure to general anesthesia (GA) may contribute to an increased risk of Alzheimer's disease. Our study examined the associations between exposure to GA compared with regional anesthesia (RA) administered for elective surgical procedures and the development of dementia. DESIGN: Population-based propensity matched retrospective cohort study. SETTING: Linked administrative databases were accessed from ICES (formerly called the Institute for Clinical Evaluative Services) in Ontario, Canada. PARTICIPANTS: We included all community-dwelling individuals aged 66 and older who underwent one of five elective surgical procedures in Ontario, Canada, between April 1, 2007, and March 31, 2011. Individuals with evidence of dementia preceding cohort entry were excluded. Individuals who received GA were matched within surgical procedures to those who received RA on age, sex, cohort entry year, and a propensity score to control for potential confounders. MEASUREMENTS: The baseline characteristics of the study sample were compared before and after matching. Individuals were followed for up to 5 years following cohort entry for the occurrence of dementia using a validated algorithm. Cox proportional hazards analysis was used to determine the hazard ratio (HR) and 95% confidence interval (CI) for the association between anesthetic type and dementia. Subgroup and sensitivity analyses were undertaken. RESULTS: A total of 7,499 matched pairs were included in the final analysis. Overall, no difference was observed in the risk of being diagnosed with dementia for individuals who received GA when compared with RA (HR = 1.0; 95% CI = .8-1.2). There was also no association between anesthesia and dementia in most subgroup and sensitivity analyses. CONCLUSION: Elective surgery using GA was not associated with an overall elevated risk of dementia when compared with RA. Future studies are required to determine whether surgery is a risk factor for dementia irrespective of anesthetic technique.

20.
BMC Pediatr ; 20(1): 488, 2020 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-33087096

RESUMO

BACKGROUND: There is no globally accepted definition for dosing error in adult or pediatric practice. The definition of pediatric dosing error varies greatly in the literature. The objective of this study was to develop a framework, informed by a set of principles, for a clinician-based definition of drug dosing errors in critically ill children, and to identify the range that practitioners agree is a dosing error for different drug classes and clinical scenarios. METHODS: We conducted a nationwide three staged modified Delphi from May to December 2019. Expert clinicians included Canadian pediatric intensive care unit (PICU) physicians, pharmacists and nurses, with a least 5 years' experience. Outcomes were underlying principles of drug dosing, and error thresholds, as defined by proportion above and below reference range, for common PICU medications and clinical scenarios. RESULTS: Forty-four participants met eligibility, and response rates were 95, 86 and 84% for all three rounds respectively. Consensus was achieved for 13 of 15 principles, and 23 of 30 error thresholds. An over-dosed drug that is intercepted, an under-dose of a possibly life-saving medication, dosing 50% above or below target range and not adjusting for a drug interaction were agreed principles of dosing error. Altough there remained much uncertainty in defining dosing error, expert clinicians agreed that, for most medication categories and clinical scenarios, dosing over or below 10% of reference range was considered an error threshold. CONCLUSION: Dosing principles and threshold are complex in pediatric critical care, and expert clinicians were uncertain about whether many scenarios were considered in error. For most intermittent medications, dosing over 10% below or above reference range was considered a dosing error, although this was largely influenced by clinical context and drug properties. This consensus driven error threshold will help guide routine clinical dosing practice, standardized reporting and drug quality improvement in pediatric critical care.

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