AIMS: The aim of this study was to compare the clinical decision-making for benzodiazepine deprescribing between a healthcare provider (HCP) and an artificial intelligence (AI) chatbot GPT4 (ChatGPT-4). METHODS: We analysed real-world data from a Croatian cohort of community-dwelling benzodiazepine patients (n = 154) within the EuroAgeism H2020 ESR 7 project. HCPs evaluated the data using pre-established deprescribing criteria to assess benzodiazepine discontinuation potential. The research team devised and tested AI prompts to ensure consistency with HCP judgements. An independent researcher employed ChatGPT-4 with predetermined prompts to simulate clinical decisions for each patient case. Data derived from human-HCP and ChatGPT-4 decisions were compared for agreement rates and Cohen's kappa. RESULTS: Both HPC and ChatGPT identified patients for benzodiazepine deprescribing (96.1% and 89.6%, respectively), showing an agreement rate of 95% (κ = .200, P = .012). Agreement on four deprescribing criteria ranged from 74.7% to 91.3% (lack of indication κ = .352, P < .001; prolonged use κ = .088, P = .280; safety concerns κ = .123, P = .006; incorrect dosage κ = .264, P = .001). Important limitations of GPT-4 responses were identified, including 22.1% ambiguous outputs, generic answers and inaccuracies, posing inappropriate decision-making risks. CONCLUSIONS: While AI-HCP agreement is substantial, sole AI reliance poses a risk for unsuitable clinical decision-making. This study's findings reveal both strengths and areas for enhancement of ChatGPT-4 in the deprescribing recommendations within a real-world sample. Our study underscores the need for additional research on chatbot functionality in patient therapy decision-making, further fostering the advancement of AI for optimal performance.
- MeSH
- benzodiazepiny škodlivé účinky MeSH
- depreskripce * MeSH
- klinické rozhodování MeSH
- lidé MeSH
- umělá inteligence * MeSH
- zdravotnický personál MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
INTRODUCTION: Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia. METHODS: Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented. RESULTS: The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8). CONCLUSIONS: Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.
- MeSH
- benzodiazepiny * terapeutické užití škodlivé účinky aplikace a dávkování MeSH
- domovy pro seniory statistika a číselné údaje MeSH
- lékařská praxe - způsoby provádění statistika a číselné údaje normy MeSH
- lidé MeSH
- nevhodné předepisování * statistika a číselné údaje MeSH
- pečovatelské domovy * statistika a číselné údaje MeSH
- polypharmacy * MeSH
- prevalence MeSH
- psychotropní léky terapeutické užití škodlivé účinky MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Chorvatsko MeSH
Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.
We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach-summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9-63.2%, and the range was 6.5-95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.
- MeSH
- lidé MeSH
- nevhodné předepisování * MeSH
- prevalence MeSH
- senioři MeSH
- studie případů a kontrol MeSH
- Check Tag
- lidé MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- systematický přehled MeSH
- Geografické názvy
- Evropa MeSH
- východní Evropa MeSH
AIMS: Community-based pharmacists are an important stakeholder in providing continuing care for chronic multi-morbid patients, and their role is steadily expanding. The aim of this study is to examine the literature exploring community-based pharmacist-initiated and/or -led deprescribing and to evaluate the impact on the success of deprescribing and clinical outcomes. METHODS: Library and clinical trials databases were searched from inception to March 2020. Studies were included if they explored deprescribing in adults, by community-based pharmacists and were available in English. Two reviewers extracted data independently using a pre-agreed data extraction template. Meta-analysis was not performed due to heterogeneity of study designs, types of intervention and outcomes. RESULTS: A total of 24 studies were included in the review. Results were grouped based on intervention method into four categories: educational interventions; interventions involving medication review, consultation or therapy management; pre-defined pharmacist-led deprescribing interventions; and pharmacist-led collaborative interventions. All types of interventions resulted in greater discontinuation of medications in comparison to usual care. Educational interventions reported financial benefits as well. Medication review by community-based pharmacist can lead to successful deprescribing of high-risk medication, but do not affect the risk or rate of falls, rate of hospitalisations, mortality or quality of life. Pharmacist-led medication review, in patients with mental illness, resulting in deprescribing improves anticholinergic side effects, memory and quality of life. Pre-defined pharmacist-led deprescribing did not reduce healthcare resource consumptions but can contribute to financial savings. Short follow-up periods prevent evaluation of long-term sustainability of deprescribing interventions. CONCLUSION: This systematic review suggests community-based pharmacists can lead deprescribing interventions and that they are valuable partners in deprescribing collaborations, providing necessary monitoring throughout tapering and post-follow-up to ensure the success of an intervention.
- MeSH
- depreskripce * MeSH
- dospělí MeSH
- farmaceuti * MeSH
- kvalita života MeSH
- lidé MeSH
- poskytování zdravotní péče MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- systematický přehled MeSH
Úvod: Předepisování negeriatrických dávek, nevhodných indikací ve stáří a interakcí lék–nemoc představuje specifické oblasti rizikové geriatrické preskripce, které mohou vést k častým polékovým komplikacím, zejména u polymorbidních seniorů s po‑lyfarmakoterapií a vyšším stupněm stařecké křehkosti. Evropský projekt SHELTER (z angl. „Services and Health in the Elderly in Long‑TERm care“, 7. rámcový program, 2009–2014) byl zaměřen na popis základních charakteristik (včetně preskripčních zvyklostí) u 4156 seniorů v zařízeních dlouhodobé ošetřovatelské péče v 7 evropských zemích (České republice, Itálii, Německu, Nizozemí, Finsku, Velké Británii, Francii) a Izraeli. Tato práce se zaměřuje na retrospektivní analýzu interakcí lék–nemoc ve stáří v českém souboru seniorů projektu SHELTER.Metodika práce: Semi‑implicitní metodou (tj. hodnocením komplexních protokolů geriatrických pacientů českého souboru evropského projektu SHELTER, červen–srpen 2019) byl retrospektivně zhodnocen výskyt interakcí lék–nemoc s využitím ex‑pertních explicitních kritérií. Jednalo se o Beersova kritéria z roku 2003 a 2012, IPET kritéria, Český expertní národní konsenzus potenciálně nevhodných lékových postupů z roku 2013, STOPP/START kritéria verze 1 a IPET kritéria. Senioři byli v projektu SHELTER vyšetřeni s pomocí komplexního geriatrického vyšetření (RAI‑LTCF verze II) v 10 regionálně odlišných zařízeních dlouhodobé ošetřovatelské péče (N = 490 seniorů, věk 65 let a více, zařazeni byli všichni senioři dlouhodobě umístění (3 a více měsíců) v účastnících se ošetřovatelských zařízeních. Ke statistickému zhodnocení byla použita popisná statistika s využitím chí ‑kvadrát (χ2) testu a Fisherova exaktního testu (p < 0,05).Výsledky: Nejvyšší prevalence užití potenciálně nevhodných interakcí lék–nemoc (64,3 %) byla popsána s pomocí Českého národního konsenzu potenciálně nevhodných léčiv z roku 2013 (z angl. CNC), dále s pomocí Beersových kritérií z roku 2012 (60,2 %), STOPP/START kritérií verze 1 (44,5 %/ 52,9 %) a IPET kritérií (30,2 %). Mezi nejčastěji užívané potenciálně nevhodné postupy identifikované s pomocí Českého národního konsenzu patřilo dlouhodobé užití benzodiazepinů (BZD) u seniorů s dia‑gnózou deprese (7,8 %), užití opioidních analgetik u pacientů s chronickou zácpou bez podání šetrných laxativ (6,3 %), užití BZD u pacientů se synkopami a pády (1 a více pádů za poslední 3 měsíce) (6,1 %) a současné dlouhodobé podávání ACE‑I a NSAID bez monitorování kalémie (6,1 %).Závěr: Užití Českého národního konsenzu (CNC) vedlo k dokumentaci nejvyšší prevalence interakcí lék–nemoc v českém souboru seniorů ve srovnání se zahraničními explicitními kritérii. S pomocí explicitních kritérií bylo v dlouhodobé ošetřovatelské péči v ČR identifikováno více než 60 % seniorů, kteří by byli prioritizováni ke komplexním intervencím klinických farmaceutů. S nově prosazeným výkonem klinických farmaceutů v ČR v ambulantní péči by se tito specialisté měli uplatnit i ve složitých lékových revizích u geriatric‑kých nemocných v primární péči, a to zejména v dlouhodobé ošetřovatelské péči, domácí péči, sociální péči a v paliativních hospicích.
Introduction: Prescribing of non-geriatric dosing, inappropriate indications and drug-disease interactions in older patients create specific areas of high-risk prescribing in geriatrics that often lead to drug-related complications, particularly in polymorbid older patients using polypharmacy and having higher degree of frailty. The European project SHELTER (Services and Health in the Elderly in Long-TERrm care, 7th FP, 2009-2014) aimed at describing comprehensive characteristics of 4 156 long-term care seniors (including drug prescribing habits) in 7 EU countries (Czech Republic, Italy, Germany, Netherlands, Finland, UK, France) and Israel. This study focuses on retrospective analyses of drug-disease interactions in the Czech sample of seniors of the SHELTER project. Methods: Semi-implicit method (evaluation of complex protocols of geriatric patients from the Czech sample of the European project SHELTER, June-August 2019) was used to retrospectively analyse the prevalence of drug-disease intereactions using expert explicit criteria. Mainly Beers criteria 2003 and 2012, Czech national consensus of potentially inappropriate medications 2013, STOPP/START criteria version I. and IPET criteria have been applied. In the SHELTER project, seniors were assessed using comprehensive geriatric assessment (RAI-LTCF vers.I) in 10 regionally different Czech (CZ) long-term care facilities (N = 490 seniors, age 65+, all patients residing for long-term (more than 3 months) in evaluated long-term care facilities). For statistical analyses, descriptive statistics has been used, namely chi-square (χ2) test and Fisher´s exact tests (p < 0,05). Results: The highest prevalence of potentially inappropriate drug-disease interactions (64.3 %) was identified using Czech national consensus of potentially inappropriate medications 2013 (CNC), then by Beers 2012 criteria (60.2 %), STOPP/START criteria version I. (44.5 %/52.9 %, respectively) and IPET criteria (30.2 %). The most prevalent prescribing problems were (according to CNC): long-term use of benzodiazepines (BZDs) in depressive patients (7.8 %), constipation caused by opioids without using laxatives-lactulose (7.3 %), long-term use of BZDs in patients suffering from syncopes and falls (1 and more falls in the past 3 months) (6.3 %) and long-term use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and ACE-I without clinical monitoring of kalemia (6.1 %). Conclusion: Application of Czech national consensus (CNC) led to documentation of the highest prevalence of drug-disease interactions in the Czech sample of seniors in long-term care in comparison to foreign explicit criteria. With the help explicit criteria we identified in Czech long-term care facilities more than 60 % of seniors potentially prioritized for complex interventions of clinical pharmacists. In the light of newly approved payments in ambulatory care for interventions of clinical pharmacists in the Czech Republic, services of these specialists should be utilized for complex drug revisions of geriatric patients in primary care, particularly in long-term care, home care, social care and palliative hospices.
Publikace shrnuje aktivity realizované v posledních 20 letech (2000–2020) v rozvoji klinické farmacie v geriatrii v oblasti klinické i výzkumné. V oblasti klinické poukazuje na významná specifika racionální geriatrické farmakoterapie oproti klasické interní medicíně a na zvláštnosti hodnocení a individualizace lékových režimů ve stáří. Vyzdvihuje významnou roli klinických farmaceutů jako specialistů v oboru klinická farmacie v individualizaci lékových režimů ve stáří, která vyžaduje hluboké znalosti klinické farmacie v geriatrii, v risk managementu, aplikované geriatrické farmakologie, znalosti současných geriatrických studií a specifických přístupů individualizované geriatrické léčby. Ve výzkumné oblasti tato publikace poukazuje na výzkumné aktivity v ČR a Evropě, které přispěly a dále přispívají k rozvoji klinické farmacie v geriatrii, a do nichž je zapojena výzkumná skupina PROGRESS Q42 KSKF 2 FaF UK „Stárnutí, polyfarmakoterapie a změny terapeutické hodnoty léčiv ve stáří“ („Aging, Polypharmacy and Changes in the Therapeutic Value of Drugs in the AgeD“ Scientific Unit), vedoucí doc. Fialová. Z výzkumných aktivit jsou v publikaci zmiňovány především analýzy racionální geriatrické farmakoterapie v evropských projektech ADHOC (AgeD in HOme Care, 5. rámcový program Evropské komise, 2001–2005), SHELTER (Services and Health in the Elderly in Long term Care, 7. rámcový program Evropské komise, 2009–2014), EU COST Action IS1402 „Ageism interdisciplinary, multiprofessional perspectives“ (2015–2018), probíhající projekt EUROAGEISM Horizont 2020 MCSF INT 764632 (2017–2021) a je zmíněn i nově podaný evropský projekt „I CARE4OLD“ v programu Horizont 2020.
Publication summarizes activities realized in the past 20 years (2000–2020) in the development of clinical pharmacy in geriatrics in clinical and scientific areas. In clinical area it emphasizes specific features of rational geriatric pharmacotherapy in comparison to classical internal medicine and specific aspects of evaluation and individualization of drug schemes in older patients. It high lights important role of clinical pharmacists as specialists in the field of clinical pharmacy in individualization of drug schemes and reguirements of deep knowledge of clinical pharmacy in geriatrics, risk management, applied geriatric pharmacology, current geriatric studies and principles of individualized geriatric pharmacotherapy. In the scientific area it summarizes significant research activities in the Czech Republic and Europe that contributed to the development of clinical pharmacy in geriatrics and in which the scientific group PROGRESS Q42 KSKF 2 of the Faculty of Pharmacy, Charles University was involved, entitled „Aging, Polyphar macy and Changes in the Therapeutic Value of Drugs in the AgeD“ (chair: Assoc. prof. Fialová). From these scientific activities are stated in this publication mainly analyses of rational geriatric pharmacotherapy in European projects ADHOC (AgeD in HOme Care, 5th Framework Program of the European Commission, 2001–2005), SHELTER (Services and Health in the Elderly in Long term Care, 7th Framework program of the European Comission, 2009–2014), EU COST Action IS1402 project „Ageism interdisciplinary, multiprofessional perspectives“ (2015–2018), currently ongoing project EUROAGEISM Horizon 2020 MCSF INT 764632 (2017–2021) and newly submitted EU project „I CARE4OLD“ in the Horizon 2020 program.
