Identifying frailty in primary care: a qualitative description of family physicians' gestalt impressions of their older adult patients.

BACKGROUND: Many tools exist to guide family physicians' impressions about frailty status of older adults, but no single tool, instrument, or set of criteria has emerged as most useful. The role of physicians' subjective impressions in frailty decisions has not been studied. This study explores how family physicians conceptualize frailty, and the factors that they consider when making subjective decisions about patients' frailty statuses. METHODS: Descriptive qualitative study of family physicians who practice in a large urban academic family medicine center as they participated in one-on-one "think-aloud" interviews about the frailty status of their patients aged 80 years and over. Of 23 eligible family physicians, 18 shared their impressions about the frailty status of their older adult patients and the factors influencing their decisions. Interviews were audio-recorded, transcribed, and thematically analyzed. RESULTS: Four themes were identified, the first of which described how physicians conceptualized frailty as a spectrum and dynamic in nature, but also struggled to conceptualize it without a formal definition in place. The remaining three themes described factors considered before determining patients' frailty statuses: physical characteristics (age, weight, medical conditions), functional characteristics (physical, cognitive, social) and living conditions (level of independence, availability of supports, physical environment). CONCLUSIONS: Family physicians viewed frailty as multifactorial, dynamic, and inclusive of functional and environmental factors. This conceptualization can be useful to make comprehensive and flexible evaluations of frailty status in conjunction with more objective frailty tools.

Benefits and Harms of Deprescribing Antihyperglycemics for Adults With Type 2 Diabetes: A Systematic Review.

OBJECTIVES: Contemporary guidelines suggest relaxed glycemic targets in populations with type 2 diabetes mellitus (T2DM) at risk of hypoglycemia, including people with multimorbidity, limited life expectancy or frailty. However, overtreatment remains commonplace. To inform safe deprescribing, a previous systematic review investigated the benefits and harms of deprescribing antihyperglycemics, but identified only limited, very low-quality evidence. We sought to update that review and identify and describe newly published literature on the effects of deprescribing antihyperglycemics in older adults with T2DM. METHODS: We searched MEDLINE, EMBASE and the Cochrane Library (July 2015 to January 2021) for controlled studies published in English addressing the effects of deprescribing vs continuing antihyperglycemics in adults with T2DM. Two independent reviewers performed title, abstract and full-text screening, data extraction and risk-of-bias assessment. Cochrane's risk-of-bias tools, RoB 2 and ROBINS-I, were used. The findings were summarized narratively. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to evaluate the evidence. RESULTS: We identified 4 additional investigations-2 randomized controlled trials and 2 retrospective cohort studies. After deprescribing, 3 studies reported no clinically significant changes in glucose management and 2 studies reported reductions in adverse events (e.g. hypoglycemia, all-cause mortality and nonspine fractures). However, based on GRADE assessment, we found very low certainty of the evidence due to concerns of risk of bias (e.g. unmeasured confounding), imprecision, and indirectness. CONCLUSIONS: Deprescribing antihyperglycemic medications in older adults with T2DM is likely feasible and safe, and benefits may outweigh the harms. However, the evidence indicates very low certainty. Additional deprescribing studies are needed with rigorous methodologies and reporting.

Pharmacists as Personalized Medicine Experts (PRIME): Experiences Implementing Pharmacist-Led Pharmacogenomic Testing in Primary Care Practices.

Research exploring the integration of pharmacogenomics (PGx) testing by pharmacists into their primary care practices (including community pharmacies) has focused on the "external" factors that impact practice implementation. In this study, additional "internal" factors, related to the capabilities, opportunities, and motivations of pharmacists that influence their ability to implement PGx testing, were analyzed. Semi-structured interview data from the Pharmacists as Personalized Medicine Experts (PRIME) study, which examined the barriers and facilitators to implementing PGx testing by pharmacists into primary care practice, were analyzed. Through thematic analysis, using the theoretical domains framework (TDF) domains as deductive codes, the authors identified the most relevant TDF domains and applied the behavioural change wheel (BCW) to generate intervention types to aid in the implementation of PGx testing. Pharmacists described how their professional identities, practice environments, self-confidence, and beliefs in the benefits of PGx impacted their ability to provide a PGx-testing service. Potential interventions to improve the implementation of the PGx service included preparing pharmacists for managing an increased patient load, helping pharmacists navigate the software and technology requirements associated with the PGx service, and streamlining workflows and documentation requirements. As interest in the wide-scale implementation of PGx testing through community pharmacies grows, additional strategies need to address the "internal" factors that influence the ability of pharmacists to integrate testing into their practices.

Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel.

BACKGROUND: Deprescribing, the planned and supervised process of stopping or reducing doses of medications, can reduce the use of harmful or unnecessary medications. However, deprescribing is challenging for patients and prescribers to implement. Community pharmacists have the potential to contribute to deprescribing, but whether they are well positioned to do so effectively remains unclear. OBJECTIVES: To explore community pharmacists' involvement with deprescribing, and identify strategies for enhancing this involvement. METHODS: We conducted qualitative telephone interviews with 17 community pharmacists in Ontario, Canada. The Behaviour Change Wheel's COM-B model was used to inform the development of the interview guide. Four investigators coded three transcripts independently to develop the codebook. One investigator coded the remainder and generated themes relating to the first study objective using inductive thematic analysis. Two phases of analysis were then used to satisfy the second study objective: the first without the explicit use of theory, and the second using the Behaviour Change Wheel as a theoretical framework. RESULTS: Pharmacists' involvement in deprescribing was affected by: 1) their understanding of which medications should be stopped and by whom, 2) their access to patient information, and 3) competing clinical and business/technical demands of their daily activities. Findings support recommendations for optimizing community pharmacists' involvement in deprescribing by focusing on specific steps within deprescribing, expanding pharmacists' understanding of how to integrate deprescribing into their practices, and defining their deprescribing role with multi-stakeholder engagement. CONCLUSIONS: This study is the first to connect community pharmacists' real-world deprescribing challenges with theory-informed recommendations for enhancing their contributions to deprescribing. This study also explored the role of theory in pragmatically-oriented qualitative work by analyzing data without the explicit use of theory as the first step to analysis. Findings inform recommendations for enhancing community pharmacists' contributions to deprescribing.