Part 3: Literature Review and Critical Appraisal Paper

Part 3: Literature Review and Critical Appraisal Paper

Part 3: Literature Review and Critical Appraisal Paper

Mediation reviews and deprescribing are proven interventions for preventing inappropriate polypharmacy. According to Dahal & Bista (2023), polypharmacy is prevalent when patients grapple with multiple co-morbid conditions, receive care from multiple specialists, and encounter personal issues that compromise compliance with pharmacologic interventions. Similarly, system-related factors like improper medication reconciliation, a poor transition of care, and over-prescription can lead to polypharmacy (Dahal & Bista, 2023). Amidst the need to prevent polypharmacy and its associated adverse outcomes, the NO TEARS tool can provide insights into steps for medication reviews and thresholds for deprescribing unnecessary medications. Consequently, this paper summarizes current scholarly evidence that supports the NO TEARS tool, medication reviews, and deprescribing as ideal strategies for preventing polypharmacy in older adults in long-term care facilities.

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Literature Review

Literature Search Strategy

The primary strategy for locating ideal evidence sources entailed utilizing keywords and subtitles consistent with the PICOT question. In this case, subtitles and keywords like deprescribing unnecessary medications, medication reviews and polypharmacy, polypharmacy prevention, medication reviews, and deprescribing, and NO TEARS tool informed practices for identifying evidence sources. Using these keywords and subtitles made it possible to identify evidence sources from reputable online databases, including PubMed, BMC, and PLOS Medicine. The search process included full-text, peer-reviewed articles published within the last five years (2018-2023) and those focused on at least one keyword and subtitles. Consequently, the search yielded five scholarly articles satisfying the inclusion criteria.

Summaries of Research Studies

There are information gaps in the current scholarly literature regarding the effectiveness of the NO TEARS tool in preventing inappropriate polypharmacy. Due to the few studies exploring this tool’s effectiveness, the reviewed studies focused on the rationale for medication reviews and deprescribing in preventing inappropriate polypharmacy. In a randomized controlled trial (RCT), Verdoorn et al. (2019) investigated the effect of patient-centered clinical mental reviews (CMRs) focused on personal goals on health-related quality of life (HR-QoL). The study involved 584 participants (294 in the intervention group and 294 in the control group) from 35 community pharmacies in the Netherlands. The researchers hypothesized that medication reviews focused on patients’ health-related goals and preferences could improve their well-being. The study revealed that the number of health problems significantly decreased by 12% in the intervention group compared to the control group (p=0.024). These findings ascertain the relevance of medication reviews in preventing health problems like inappropriate polypharmacy.

In a scoping review, Lee et al. (2020) explore the evidence-based strategies for preventing potentially inappropriate polypharmacy (PIP) for older adults with multi-morbidity in outpatient care settings. The researchers reviewed 80 scholarly articles from PubMed, CINAHL, EMBASE, Cochrane, and Web of Science. After a comprehensive review of the eligible studies, the study reveals that the current scholarly literature supports comprehensive medication reviews, checklists and guidelines for medication reviews, shared decision-making, patient interviewing, and education as ideal strategies for preventing potentially inappropriate prescriptions (PIPs).

Kurczewska-Michalak et al. (2021) reveal similar findings after conducting a scoping review of the available interventions for polypharmacy management in older adults. The study involved 49 articles published between January 2010-March 2018 and indexed in scientific databases, including PubMed, CINAHL, and EMBASE. Kurczewska-Michalak et al. (2021) identified various themes from the reviewed publications. These themes include deprescribing (7 studies), optimal/appropriate prescribing (5 articles), drug reviews (18 articles), medication reviews with follow-up (2 studies), collaborative physician-pharmacist medication therapy management (4 studies), and validated screening tools like STOPP/START (19 studies). These themes represent evidence-based strategies for preventing polypharmacy.

Quantitative studies in different settings support the rationale for deprescribing and medication reviews to prevent polypharmacy. In a systematic review and meta-analysis of randomized and cluster randomized trials, Bloomfield et al. (2020) revealed consistent findings across the reviewed 47 studies. These studies emphasized the effectiveness of comprehensive medication reviews, educational interventions, and computerized decision support as ideal approaches for preventing polypharmacy (Bloomfield et al., 2020). The study associates these interventions with positive health outcomes, including preventing mortality, hospitalizations, and falls.

In another sustenance review of randomized controlled trials (RCTs), pre-and post-comparison studies, and prospective interventional cohort study, Ibrahim et al. (2021) summarize the current evidence for deprescribing among older adults living with frailty. According to Ibrahim et al. (2021), the reviewed six eligible quantitative studies support various deprescribing strategies, including pharmacist-led deprescribing and multidisciplinary team (MDT)-led deprescribing. The reviewed studies associated deprescribing methods with positive outcomes like reduced adverse events, including falls, fractures, delirium, and depression.

Critical Appraisal of Literature

The reviewed five qualitative and quantitative studies justify the rationale for implementing comprehensive medication reviews and deprescribing strategies in preventing inappropriate polypharmacy among older adults grappling with multi-morbidity. These studies satisfy various thresholds for credible evidence sources, including a proper statement of purpose, clear demonstration of interventions and instruments, discussion about inclusion and exclusion criteria, and comprehensive statistical and non-statistical (qualitative) data analysis. In the reviewed quantitative studies (Verdoorn et al., 2021; Bloomfield et al., 2020; Ibrahim et al., 2021), the primary strengths include randomization of participants, blinding, and the use of pre-tests and t-tests to evaluate inter-group differences before and after intervention.

Blinding and randomization are profound approaches for eliminating biases and preventing placebo effects that may compromise the results’ validity, reliability, and accuracy. Eliminating biases and placebo effects can contribute to the results’ generalizability and transferability. The researchers identified various strengths associated with the study designs and instruments in the reviewed qualitative studies (Lee et al., 2020; Kurczewska-Michalak et al., 2021). For instance, Lee et al. (2020) identified the study’s strengths by developing a step-by-step protocol for the systematic review, documentation of all search iterations, and a comprehensive search for peer-reviewed and grey literature. On the other hand, Kurczewska-Michalak et al. (2021) identified a comprehensive review of available methods of preventing polypharmacy as a significant strength that may enable stakeholders to make informed decisions. Although these studies have limitations, these strengths justify their eligibility, validity, and generalizability.

Conclusion

This literature review aimed to explore the current evidence supporting the application of the NO TEAR medication review and deprescribing tool in preventing inappropriate polypharmacy in older adults with multi-morbidity. A comprehensive search for ideal evidence sources identified information gaps due to limited studies that explore the effectiveness of the NO TEARS tool in polypharmacy prevention. Amidst this information gap, the subsequent search strategies focused on qualitative and quantitative research studies that justify the effectiveness of medication reviews and deprescribing in preventing polypharmacy. Therefore, five studies satisfied the inclusion criteria and provided insights into the foreground question. These studies are up-to-date, reliable, valid, and generalizable in other clinical contexts.

References

Bloomfield, H. E., Greer, N., Linsky, A. M., Bolduc, J., Naidl, T., Vardeny, O., MacDonald, R., McKenzie, L., & Wilt, T. J. (2020). Deprescribing for community-dwelling older adults: A systematic review and meta-analysis. Journal of General Internal Medicine, 35(11), 3323–3332. https://doi.org/10.1007/s11606-020-06089-2

Dahal, R., & Bista, S. (2023). Strategies to reduce polypharmacy in the elderly. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574550/

Ibrahim, K., Cox, N. J., Stevenson, J. M., Lim, S., Fraser, S. D. S., & Roberts, H. C. (2021). A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatrics, 21(1). https://doi.org/10.1186/s12877-021-02208-8

Kurczewska-Michalak, M., Lewek, P., Jankowska-Polańska, B., Giardini, A., Granata, N., Maffoni, M., Costa, E., Midão, L., & Kardas, P. (2021). Polypharmacy management in the older adults: A scoping review of available interventions. Frontiers in Pharmacology, 12. https://doi.org/10.3389/fphar.2021.734045

Lee, J. Q., Ying, K., Lun, P., Tan, K. T., Ang, W., Munro, Y., & Ding, Y. Y. (2020). Intervention elements to reduce inappropriate prescribing for older adults with multimorbidity receiving outpatient care: A scoping review. BMJ Open, 10(8), e039543. https://doi.org/10.1136/bmjopen-2020-039543

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer Health.

Verdoorn, S., Kwint, H.-F., Blom, J. W., Gussekloo, J., & Bouvy, M. L. (2019). Effects of a clinical medication review focused on personal goals, quality of life, and health problems in older persons with polypharmacy: A randomized controlled trial (DREAMeR-study). PLOS Medicine, 16(5), e1002798. https://doi.org/10.1371/journal.pmed.1002798

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Assignment Prompt

This week’s first assignment is STEP 3 – Literature Review and Critical Appraisal.

The student will complete the following items and submit a Word doc to the assignment link.

1. Provide a title that conveys or describes the assignment.
2. Literature Review – Provide the key terms used to guide the search for the evidence and provide at least five (5) summaries of research studies to support the evidence.
3. Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and any gaps in knowledge from the research evidence.
4. References – Cite a minimum of five scholarly references in APA 6th ed format.