Patient-Directed Education to Promote Deprescribing: A Nonrandomized Clinical Trial.

IF 22.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL JAMA Internal Medicine Pub Date : 2024-11-01 DOI:10.1001/jamainternmed.2024.4739
Katie Fitzgerald Jones, Kelly Stolzmann, Jolie Wormwood, Jacquelyn Pendergast, Christopher J Miller, Michael Still, Barbara G Bokhour, Joseph Hanlon, Steven R Simon, Amy K Rosen, Amy M Linsky
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Abstract

Importance: Patient-directed educational materials are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks.

Objective: To examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit (proton pump inhibitors) or high-risk medications (high-dose gabapentin, diabetes agents with hypoglycemia risks).

Design, setting, and participants: This pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct US Veterans Affairs (VA) medical centers from April 2021 to October 2022. The total study sample was composed of the intervention cohort and the historical control cohort cared for by 103 primary care practitioners (PCPs).

Intervention: The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to all eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same PCPs at the same sites 1 year prior to the study intervention served as controls.

Main outcome and measures: The primary binary outcome variable was deprescribing 6 months after the intervention, defined as complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data.

Results: The total study sample included 5071 patients. The overall rate of deprescribing among the intervention cohort (n = 2539) was 29.5% compared with 25.8% among the controls (n = 2532). In an unadjusted model, the intervention cohort was statistically significantly more likely to have deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = .02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = .008). The difference in deprescribing prevalence between the intervention and control cohorts (proton pump inhibitors: 29.4% vs 25.4%; gabapentin: 40.2% vs 36.2%; hypoglycemia risk: 27.3% vs 25.1%) did not statistically significantly differ by medication group (P = .90).

Conclusion and relevance: This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups.

Trial registration: ClinicalTrials.gov Identifier: NCT0429490.

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通过患者指导教育促进去处方化:非随机临床试验。
重要性:以患者为导向的教育材料是一种很有前景的实施策略,可扩大处方的覆盖面和采用率,但对具有潜在不同感知风险的药物组的影响却知之甚少:目的:研究以患者为导向的教育干预对临床医生开具潜在低效药物(质子泵抑制剂)或高风险药物(大剂量加巴喷丁、有低血糖风险的糖尿病药物)处方的影响:这项务实的多地点非随机临床试验于 2021 年 4 月至 2022 年 10 月在 3 个地理位置不同的美国退伍军人事务(VA)医疗中心进行。研究样本包括干预队列和历史对照队列,由 103 名初级保健医生(PCPs)负责护理:干预措施的主要内容是在干预期间向所有符合条件的患者在预约初级保健医生前 2 到 3 周邮寄一份药物治疗小册子。研究干预前一年在同一地点由相同初级保健医生诊治的患者作为对照组:主要的二元结果变量是干预后 6 个月的停药情况,根据退伍军人药房的配药数据,停药的定义是完全停止或减少目标药物的剂量:研究样本共包括 5071 名患者。干预组患者(n = 2539)的总减药率为 29.5%,而对照组患者(n = 2532)的减药率为 25.8%。在未经调整的模型中,干预队列中出现去处方化的可能性明显更高(几率比 [OR],1.17 [95% CI,1.03-1.33];P = .02)。在一个多变量逻辑回归模型中,将患者和初级保健医生嵌套在同一地点,并控制患者和初级保健医生的特征,干预队列的去处方化几率是对照队列的 1.21 倍(95% CI,1.05-1.38;P = .008)。干预组群与对照组群的处方开具率差异(质子泵抑制剂:29.4% vs 25.4%; P = .008):29.4% vs 25.4%;加巴喷丁:40.2% vs 36.2%;低血糖风险:27.3% vs 25.1%)在统计学上并无显著差异(P = .90):这项非随机临床试验发现,在预约初级保健服务之前提供由患者指导的教育材料,可以有效促进潜在的低效益和高风险药物组的处方减少:试验注册:ClinicalTrials.gov Identifier:NCT0429490。
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来源期刊
JAMA Internal Medicine
JAMA Internal Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
43.50
自引率
1.30%
发文量
371
期刊介绍: JAMA Internal Medicine is an international, peer-reviewed journal committed to advancing the field of internal medicine worldwide. With a focus on four core priorities—clinical relevance, clinical practice change, credibility, and effective communication—the journal aims to provide indispensable and trustworthy peer-reviewed evidence. Catering to academics, clinicians, educators, researchers, and trainees across the entire spectrum of internal medicine, including general internal medicine and subspecialties, JAMA Internal Medicine publishes innovative and clinically relevant research. The journal strives to deliver stimulating articles that educate and inform readers with the latest research findings, driving positive change in healthcare systems and patient care delivery. As a member of the JAMA Network, a consortium of peer-reviewed medical publications, JAMA Internal Medicine plays a pivotal role in shaping the discourse and advancing patient care in internal medicine.
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