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POLYPHARMACY IN ADULTSBrandi MalsyAuburn University/ Auburn MontgomeryPolypharmacy in AdultsAbstractThe use of multiple medications, or polypharmacy, is becoming an increasingly serious problem within the healthcare system, particularly in the older adult population. Although some degree of adverse effects of medications may be unavoidable healthcare providers play an important role in the reduction and prevention of problems caused by polypharmacy within the older adult and elderly population. In order to reduce the risk of polypharmacy, a multidisciplinary approach is needed. Physicians, advance practice nurses, and pharmacists must encourage communication, ask about medications and supplements patients may use, and encourage patients to actively participate in their care. Polypharmacy in AdultsThe definition of polypharmacy may vary from one individual to another. The two most common definitions of polypharmacy are: 1) the use of multiple medications by an individual patient (Bushardt et al., 2008) and 2) the use of more medications than are clinically indicated (Riker et al., 2012). The definition chosen for this evidence-based practice project is: the use of multiple medications by and individual patient. Polypharmacy not only includes the consumption of prescription medications, but also consists of the consumption of over-the-counter (OTC) medications, vitamins, minerals, and herbal supplements. The use of multiple medications, or polypharmacy, is becoming an increasingly serious problem within the healthcare system, particularly in the older adult population. A century ago, one individual in 20 was aged 65 years or over, now one in six is, and by 2050 it is expected to be one in four (Nobil, Garrratini, & Mannucci, 2011). There are multiple factors that place the elderly population at risk for polypharmacy such as their more advanced disease processes and comorbidities, their overall lack of knowledge regarding possible reactions with over-the-counter (OTC) medications when combined with prescription medications. Riker et al. (2012) states, with an increase in specialization across medicine, many older adults and elderly patients see multiple prescribers and may fill medications at multiple pharmacies. With the increase of patients seeing multiple providers, the likelihood of redundancy and duplication of medications are common due to the lack of coordination between medication regimens, thus leading to the potential harm of the patient. According to Chandra and Gerwig (2007), in addition to prescribed medications, it is estimated Americans purchase approximately 5 billion OTC drugs per year, hoping to treat routine medical problems. Many individuals believe OTC medications are harmless and do not pose the same safety risks as prescribed medications because they are easily obtained. The common misconception among older adults and elderly taking OTC medications is that OTC medications are safer than prescription drugs, OTC medications do not have side effects, and OTC medications will not interact with their prescription medications. Recent studies estimate as many as 60 million consumers use some type of vitamin, herbal, or dietary supplement and tend not to share this information with their primary care provider or pharmacists. (Haque, 2009).With greater consumption of medications, polypharmacy, comes the risk of medication-related problems. Polypharmacy can lead to adverse drug reactions (ADRs), falls, unnecessary hospitalizations and physician office visits, drug-drug interactions (DDIs), and compliance issues (Riker et al., 2012). The likelihood of harm due to polypharmacy is higher in the older adult population due to the effects the aging process. With age, the ability to absorb, metabolize, and excrete medications in the intended ways become altered, therefore, producing increased or sub therapeutic levels of medications within the body. Fulton and Allen (2005) states, decreasing cognition, self-medication, and lack of knowledge of proper medication use and storage also increases the chance of harm within the older adult and elderly population. Primary care providers and specialists also contribute to the problem of polypharmacy. When patients visit their primary care provider or specialist, they generally expect to leave with a prescription. The more prescriptions an individual receives, the higher chance of harm due to polypharmacy exists. In a study in 2009, it was found providers felt it was easier to write a prescription for the patient than to spend time educating them (Prybys et al., 2012).Although polypharmacy can be of harm to individuals, it is often necessary in order to properly treat complex, chronic medical conditions. Although some degree of adverse effects of medications may be unavoidable, healthcare providers can play an important role in the reduction and prevention of problems caused by polypharmacy within the older adult population.PICO QuestionIn adults, age 50 and above with polypharmacy use, how does providing enhanced patient education regarding safe medication usage and the importance of patient communication and collaboration with healthcare providers compared with routine medication education improve the patient’s overall knowledge of medication safety, reduce the occurrence of unnecessary polypharmacy, and prevent ADRs?P- Population: “In adults, age 50 and above with polypharmacy use”The population of this EBP project will be aimed at adults age 50 and above who have been identified with polypharmacy use, or taking more than five medications daily.I- Intervention: “how does providing enhanced patient education regarding safe medication usage and the importance of patient communication and collaboration with healthcare providers”The intervention component of this EBP project will allow for enhanced medication education to be given regarding safe medication usage and the importance of adherence to the prescribed medication regimen. The intervention component will also emphasize the importance or patient-provider communication regarding the patient’s current medication regimen. C- Comparison: “compared with routine medication education”The comparison component will be done by comparing the patient’s understanding and intention of their medication regimen before education is provided against their knowledge after enhanced medication education is given.O- Outcome: “improve the patient’s overall knowledge of medication safety and reduce the occurrence of unnecessary polypharmacy, and prevent ADRs”The desired outcome of this EBP project is to improve patient’s overall knowledge of safe medication usage in order to prevent harm. FrameworkMelnyk and Fineout-Overholt (2011) explains, evidence-based practice has been recognized as the gold standard of care, prompting many healthcare organizations to invest resources into the creation of a culture that sustains the use of evidence for direct care decision making The model chosen for this project is Advancing Research and Clinical Practice Thro-ugh Close Collaboration Model: A System-wide Implementation and Sustainability of Evidence-Based Practice (ARCC). The purpose of the ARCC is to provide healthcare institutions and clinical settings with organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes (Melnyk & Fineout-Overholt, 2011). The ARCC model uses a mentor in order to assist in behavioral and organizational changes in order to implement evidence-based practice strategies. Communication barriers exist between patient and physicians in both primary and acute care settings, which further complicates the problem of polypharmacy. The ARCC Model, through the use of a mentor, has the potential to alleviate communication barriers and decrease the crisis of polypharmacy by guiding behavioral changes within the clinical community to become more aware of the prevalence and danger of polypharmacy. The need for system-wide implementation of evidence-based practice regarding polypharmacy is crucial in improving outcomes for patient’s as well as primary and acute care organizations. Education of healthcare providers of the importance and benefit of implementing and sustaining evidence-based practice into their practice will not only benefit the patient, but will increase the quality of care rendered. Review of LiteratureInappropriate Prescribing and Underuse of MedicationsIn older adults and elderly with chronic diseases, multiple medications are clinically necessary in order to therapeutically treat the disease process. With the increase of number of drugs prescribed, the likelihood of drug-drug interactions, adverse drug events (ADEs), hospitalization, and death increases (Steinman et al., 2006). The objective of this descriptive, cross-sectional study is to evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients. This study evaluated 196 outpatients in a Veteran’s Affairs (VA) Medical Center, aged 65 and older who were taking five or more medications. Data was collected from individuals through an in-person interview with a pharmacist in which the patient was asked to bring in all their medications whether prescribe the VA or not. Medical history and The Medication Appropriateness Index (MAI) and Beers criteria were used to determine the possible inappropriate prescribing of the medications, while underuse of medications was assessed using the Assessment of Underutilization and Medications Instrument. The outcome measures were the presence of inappropriately prescribed or underused medications in relation to the number of medications prescribed. Major findings of this study are that inappropriately prescribed and underuse of medications are common in older adults taking five or more medications, resulting in 40% of the individuals who participated in this study. It was also found that inappropriate medication use is more frequent in patients taking many medications, but underuse is also common. The significance of this study to this EBP project is the prevalence of underuse and inappropriately prescribed medications is directly related to the number of medications prescribed.Polypharmacy in Primary CarePolypharmacy, like the older population, is increasing in the United States. Chronic diseases are common within the older adult population, requiring multiple medications in order to manage. Due to the management of chronic diseases within the primary care setting, the ability to identify and intervene in patients with polypharmacy is crucial (Fulton & Allen, 2005). The objective of this systematic review was to evaluate literature addressing polypharmacy in individuals age 60 and older in order to (a) determine primary care providers’ definition of polypharmacy, (b) determine how polypharmacy was assessed in the primary care setting, and (c) seek tested interventions that address polypharmacy. Data was collected from electronic databases using the search terms “polypharmacy”, “polypharmacy and elderly”, “polypharmacy and research”, “and “multiple medications” for the period of January 1991 to October 2003. Sixteen articles were retrieved within this search. The outcomes measured were the various assessment techniques and interventions used within the primary care setting in order to address the prevalence of polypharmacy. The significance of this study to this EBP project is the importance in distinguishing the best intervention to use in the primary care setting in order to manage patients with polypharmacy. Interventions include: using the Beers criteria, the brown bag approach for patients, and using the definition “the use of medications that are not clinically indicated”, for the term polypharmacy. Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsMark Beers, MD recognized more than 2 decades ago, the prevention of adverse drug events in older people is crucial to the public health of our aging population. The Beers Criteria was developed as a tool to be used by healthcare providers in order to improve the awareness of and clinical outcomes for older adults with polypharmacy and for the vulnerable older adults at risk of adverse drug events (American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012; Beers et al., 1991). The objective of this systematic review is to provide a clinical practice guideline in order to improve care of the older adults by reducing their exposure to potentially inappropriate medications (PIMs) and to update the previous Beers Criteria. This systematic review consisted of 2,169 unduplicated citations consisting of 446 systematic reviews, 629 randomized controlled trials, and 1094 observational studies. A research panel divided into four criteria-specific groups analyzed citations relevant to their assigned criteria in order to determine which citations should be included in the updated criteria table. The outcomes measured were the recommendations for PIM use in older adults. Major findings in this article were: (a) each medication provided on table provides rationale for use or reason for avoidance, (b) medications are provided on the table in groups such as organ system/therapeutic category for easy reference. The significance of this study for this EBP project is this clinical guideline provides a valid up-to-date medication tool to use when assessing older adult’s medication lists. STOPP and START Screening ToolPeople who are taking multiple medications are at greater risk of ADEs, drug-drug interactions, and drug-disease interactions. ADEs lead to increased healthcare utilization and are responsible for up to 30% of hospital admission of older people. Inappropriate prescribing is a major cause of ADEs in older people (Gallagher, Ryan, Byrne, Kennedy, & O'Mahony, 2008). The objective of this systematic review is to provide a screening tool of older persons’ prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Person’s Prescriptions) and the criteria for potentially inappropriate, indicated drugs called START (Screening Tool to Alert doctors to Right Treatment). This systematic review was conducted by an 18-member expert panel, using the Delphi consensus technique in order to establish the content validity. Two rounds of questionnaires were completed. The questionnaires consisted of 68 STOPP criteria and 22 START criteria. The first round of questionnaires were answered using a 5-point Likert scale. Each panelist had the ability to answer the question as well as provide additional comments regarding each medication. The second round of questionnaires were mailed, with comments shown, in order to allow other panelists to formulate a professional opinion on the appropriateness of each medication. The outcomes measured were the consensus identification of criteria for all 22 START medications and 65 of 68 STOPP medications. The major findings in the study provided rationale for using or avoiding certain medications using the START and STOPP method within the older adult population. The three medications found within the STOPP method in which consensus was not obtained, the rationales were provided for prescribers to take into consideration. The significance of this study to this EBP project is the formulation of rationales for safe use or cautious use of identified medications within the START and STOPP tool. The Need for Increased Patient-Provider Communication and Patient EducationInterpersonal communication plays a key role in the health behavior change process. Good communication between a patient and their physician leads to an overall improvement in physical health, chronic disease management, and a better quality of life in regards to patient health (Takane, Balignasay, & Nigg, 2013). The objective of this observational study is to evaluate the perceived issues regarding medication use, including any communication challenges with providers. The study consisted of 21 participants in a Section 8 housing district in Hawaii. Data was collected via a self-administered paper survey which included questions regarding knowledge of medications and perception of patient-provider communication. Some of the questions were obtained from the Hyperpharmacoptherapy Assessment Tool (Bergman-Evans, 2006) regarding Beers M H Ouslander J G Rollinger I Reuben D R Brooks J Beck J C 1991 Explicit criteria for determining inappropriate medication use in nursing home residents.20131006152121613448381 number of medications used, perceptions of communication between patient and provider, number of physicians visited, and number of pharmacies used. There was also a section addressing the individuals’ knowledge of medications such as intended use, side effects, and proper instructions for use. The outcomes measured were the perception of communication and overall knowledge of daily medication regimen in order to find areas in need of further education. Major findings in this study are that patients cannot fully describe their medications and their intended purposes and side effects. Also, the need for interventions that focus on communication regarding polypharmacy and medication review education is needed. The significance of this study to this EBP is the prevalence of lack of medication knowledge within patients identified with polypharmacy, the need for routine medication reviews, and the importance of patient-provider communication. Inappropriate Prescribing in Primary CareBregnhoj, Thirstrup, Kristensen, Bjerrum, and Sonne (2007), identifies inappropriate prescribing being a common problem among elderly patients that causes many preventable adverse events and treatment failures. The prevalence of inappropriate prescribing leads to and overconsumption of medications and hospitalizations, and can be identified within the primary care setting. The objective of this cross-sectional study is to describe the prevalence of inappropriate prescribing in primary care according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. This study evaluated 212 elderly (>65 years) polypharmacy patients (taking five or more medications). Data was collected from individuals via a databases recording within Danish pharmacies within Copenhagen County. Data included medications prescribed by patients’ general practitioner (GP) over a 3 month period. The MAI was used to evaluate each patient’s medication regimen, while taking into consideration the patient’s medical history which was provided by their GP. A MAI was scored for medications prescribed to the patients. The outcomes of this study was the prevalence of inappropriate medications being prescribed in the primary care setting. Major findings in this study were that the therapeutic groups most commonly involved in inappropriate prescribing were medications used to treat peptic ulcer disease, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics, and anti-asthmatic medications. The significance of this study to this EBP project is the identification of classes of medications that are most often inappropriately prescribed. This finding will prompt this author for the need of increased focus when medications from these classes are identified within a patient’s medication regimen. Critical Appraisal of EvidenceThe above discussed articles were evaluated for their strengths and weaknesses, and an evidence-review grid is provided for clarification. (See Appendix A). The critical appraisal of the literature reviewed included one clinical practice guideline, two systematic reviews, two cross-sectional studies, and one observational study. Significant implications for the identification and reduction of polypharmacy within the adult population was gathered through the critical appraisal of these studies. The clinical practice guideline provides a level of evidence of I. Its purpose was to provide guidelines for practice in order to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs). The clinical practice guideline, focusing on the Beers criteria, provided significant data such as an up-to-date medication tool to assist in the assessment of older adult’s medications. The Beers criteria is a medication tool used by physicians that provides recommendations for medication use in the older adult population, including the quality of evidence and strengths for recommendations. Each medication is provided on a table with rationales for use or reason for avoidance (American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012; Beers et al., 1991). The critical appraisal of evidence of the clinical practice guideline provided significance to this EBP project by providing guidelines for use in assessing older adults’ medication lists. Two systematic reviews, both with a level of evidence of I, were included within the critical appraisal of evidence. The first systematic reviews’ purpose was to determine a consensus definition of polypharmacy among primary healthcare providers. It also explored various ways in which polypharmacy was addressed within the primary care setting, and evaluated tested interventions that addressed polypharmacy. An example of a tested intervention addressed within the systematic review include the brown bag approach for encouraging patients to bring their medications to every visit. The first systematic review also provided data to suggest the occurrence of polypharmacy is increased with the amount of physician visits yearly, but decreased when medication screening tools were used by the physician such as the Beers criteria or MAI (Fulton & Allen, 2005). The critical appraisal of evidence within the first systematic review provided significance to this EBP project by portraying the benefits of using a medication screening tool within the primary care setting.The second systematic review’s purpose was also to evaluate the benefits of using a medication screening tool within the older adult population, focusing on specific criteria for PIMs. The START and STOPP tool used for medication reviews provides rationales for using or avoiding specific medications within the older adult population (Gallagher, Bryne, Kennedy, & O'Mahony, 2008). The critical appraisal of evidence within the second systematic review provided significance to this EBP project by identifying the prevalence of underused and inappropriately prescribed medications is directly related to the number of medications prescribed. Two cross-sectional studies, with a level of evidence of IV, were included within the critical appraisal of evidence. The first cross-sectional study’s purpose was to evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by a single patient. The critical appraisal of evidence of the first cross-sectional study provided significance to this EBP project by concluding the prevalence of underuse and inappropriately prescribed medications is directly related to the number of medications prescribed (Steinman et al., 2006). The second cross-sectional study’s purpose was to describe the prevalence of inappropriate prescribing in primary care, using the MAI, and to identify specific classes of medications that were most often inappropriately prescribed to older adults (Bregnhoj, Thirstrup, & Sonne, 2007). By identifying these specific classes of high-risk medications, this will allow for an increased focus when medications from these classes are identified within a patient’s medication regimen. One observational study, with a level of evidence of IV, was included in the critical appraisal of evidence. The focus of the observational study was to evaluate the perceived issues regarding medication use within the primary care setting, including any communication challenges between patient and provider. The critical appraisal of evidence of this observational study provided sifnigicance to this EBP project by portraying the lack of knowledge regarding medications is prevalent within the older adult population. Therefore, the importance of patient-provider communication and need for routine medication reviews are evident within the primary care setting (Takane, Balignasay, & Nigg, 2013).Recommendations for Evidence-Based Practice ProjectBased on the literature review and critical appraisal of evidence, the following recommendations are made for this project:1) Encourage patients to maintain and bring an up-to-date list of all medications they are taking to every physician visit. Recommendation Grade A. 2) Healthcare providers should conduct a medication review and clarify indications of medications at every visit. Recommendation Grade A. 3) Encourage patients to participate in their care and ask questions when necessary. Recommendation Grade B. 4) Encourage patients to use only one pharmacy. Recommendation Grade B. Clinical Setting AssessmentMany patients do not realize the potential harmful effects of taking multiple medications, and thorough medication reviews and medication education is often not provided to patients by physicians. Piedmont Family Practice is a rural family practice setting in Piedmont, Alabama. Key stakeholders include two physicians, one registered nurse, and two licensed practical nurses. The average number of patients seen in this practice is 150 patients per week, with approximately 75 of these patients over the age of 50 who are prescribed or are taking five or more medications on a daily basis. The majority of patients seen in this office have chronic medical conditions and are disabled. Polypharmacy and the potential for adverse effects due to polypharmacy are prevalent in this clinical setting, and areas for improvement were identified. The first potential area for improvement is by improving the process of routine medication reviews. Within this clinical setting, medication reviews are performed on patients by the physicians at every office visit. However, there is not a standardized approach such as specific guidelines for reviewing or a specific tool that is used for medication review used by either physicians. The second potential area for improvement identified is the need for medication education to be provided to patients on a routine basis as medication education is presently only provided if the patient specifically asks. The primary physician of the clinical setting recognizes and has expressed the importance of and need for improved medication evaluation and education of his patients. Implementation PlanIn order to reduce the risks of polypharmacy, a multidisciplinary approach is needed. The primary care physicians, nurses, and project leader will become more involved in patient care, identifying areas of improvement within the practice and intervening in order to improve the overall well-being and safety of the patients involved. In order to appropriately address and improve the issue of polypharmacy within the primary care setting, specific interventions will need to take place. These interventions include: the assessment within the identified population of polypharmacy, assessment of any patient-provider communication barriers, the implementation of routine reviewing of medications at every office visit, providing medication education to patients who are identified at need, and follow-up with patients once additional medication education is provided. In order for these interventions to take place, a sense of importance and urgency must be created within the primary care setting. The physicians within the clinical setting are aware of the importance of addressing polypharmacy. Barriers to this step of the implementation process is the nurses’ lack of knowledge regarding polypharmacy and its risks. Therefore, the project leader will need to provide education to the nurses on the importance of identifying and providing education to patient’s identified with polypharmacy. Once a sense of urgency is obtained and education is provided for the nurses, responsibilities of team members will be decided. The physicians will assist the project leader in the determination of responsibilities. Obtaining a sense of urgency and having all members of the team, physicians, nurses, and project leader, involved will assist in the successful implementation of this EBP project. Resources needed for this step of the implementation process include the project leader providing the other team members on the significance of the EBP project and providing information regarding the importance of reducing polypharmacy in the adult population. With the assistance of team members, the project leader will identify patients who will be included in the EBP project by obtaining personal history, medication history, and reviewing patients’ current medication regimen. Resources needed for this step of the implementation process include access to patients’ medication regimen. This information is already being obtained by the physicians and nurses within the clinical setting. Therefore, the project leader will assist the physicians and nurses with this process, along with conducting chart reviews of the patients. Barriers to this step of the implementation process include the patients’ lack of knowledge on the dangers of polypharmacy and the project leaders’ lack of familiarity of the patients within the clinical setting. Therefore, the importance of the nurses and physicians being involved, and familiarly of the patients, is crucial for the successful implementation of the EBP project. Their familiarity of the patients will enable the project leader to distinguish which patients are at risk for polypharmacy and patients who will be most beneficial in participating in the EBP project. Once patients are selected for the EBP project, the goals of the project will be explained and written consent form will be provided for patients to complete. Therefore, face-to-face communication with the patients will be very is important in this step of implementing the EBP project. The assessment of patients’ current knowledge of their medication regimen and assessment of patient-provider communication skills will be the next step in the implementation process of the EBP project. Patients’ current medication knowledge will be assessed in the following areas: each medication’s intended use, expected side effects, and proper dosing schedule. A standardized medication reconciliation form will be provided for the patient in order to keep an accurate and up-to-date list of their medications (Gleason, Brake, Agramonte, & Perfetti, 2012). Patients will be encouraged to maintain an up-to-date list of their medications, and provide this list at every visit. Patient-provider communication barriers will also be evaluated during this step of the implementation process. Chandra and Gerwig (2007) states, appropriate and timely communication among the consumer and physician is essential for preventing polypharmacy. Having patients discuss medications with a physician is one of the most important factors in preventing drug interactions and ADEs. All team members will be involved in this step of the implementation of the EBP project. Physician involvement will be beneficial in this step of the implementation of the EBP project by encouraging patients to be involved in their care by maintaining an up-to-date list of their current medications and by providing ample time at office visits to answer any questions regarding medications the patient may have. The assessment for further medication education will be primarily implemented by project leader and the nurses. Patients who are in additional need of medication education will be provided written education materials obtained from the Care Notes program. Barriers identified in this area of implementation are the potential for patients’ inability to understand the medication education that is provided to them and patient’s not providing an up-to-date list of their medications. In order to decrease this potential barrier, education will be provided in an easy-to-understand format and patients will be encouraged by all team members to maintain an up-to-date list of their medications. Resources needed for this step of implementation will be the medication reconciliation tool and the Care Notes medication education program.Evaluation Plan Long term expected outcomes for the project includes clinical practice changes regarding patients identified with polypharmacy in order to increase individuals’ overall medication knowledge, improve medication adherence, and to decrease the occurrence of adverse drug reactions (ADR). These practice changes include: assessment of polypharmacy on patients ages 50 and older at every office visit, encourage patients to maintain and bring an up-to-date list of all medications they are taking to every visit, healthcare providers will conduct a medication review with medication reconciliation and clarify indications of each medications for every patient at every office visit, encourage patients to participate in their care and ask questions when necessary, and encourage patients to use only one pharmacy. The short-term outcomes of the EBP project should focus on providing medication education and improving communication between patients and healthcare providers. The short-term expected outcomes for the project include: increasing individuals’ overall knowledge of their medication regimen in order to decrease occurrence of ADRs. Data for this EBP project will be gathered by use of a questionnaire, review of existing medical records, and personal interviews. The questionnaire is a revised portion of the Hyperpharmacotherapy Assessment Tool (HAT) (Bergman-Evans, 2006). The questionnaire derived from the HAT will consist of questions that will be answered by the patient using a numerical scale. The questionnaire will address the number of medications being taken, number of physicians the patient sees, and number of pharmacies used by the patient. The questionnaire will also consist of yes/no questions in order to evaluate the patients’ perception of patient-provider communication and knowledge of their current medication regimen such as each medications intended purpose, proper use, and expected side effects. Data from existing medical records will be used to assess the prevalence of any previous history of ADRs that have been experienced by the patient. After information is obtained from the questionnaire and medical records, a personal interview with the patient will be conducted. Once medication education is provided to patients who are determined to be in need, outcome data will be measured by personal interviews at physician office visits or by follow-up phone calls. A potential plan for tracking outcome measures before the EBP project is implemented will involve the project leader, two physicians, and nurses within the clinical setting. Information will be gathered regarding patient descriptive data and results from questionnaire, allowing for the identification of each patient’s baseline need for additional medication education. Medication education will be provided to the identified patients. A thorough medication review will be conducted at every office visit, focusing on the patient’s ability to understand their medication regimen. Medication reviews will take place over a six month period, and ongoing education will be provided for patients who lack an understanding of safe medication usage. The project leader and nurses will evaluate the outcome data after the implementation of the EBP project. After the implementation of the EBP project, patients’ outcome data will be managed on follow-up visits by determining the ability of the patient to explain each of their medications’ intended uses, side effects, and proper dosage. If participating patients are not available to evaluate within the clinical setting, follow-up phone calls to the patient will be conducted by the project leader.Small Test of ChangeComponents of Small Test of ChangeThe purpose of this project was to improve patients’ understanding of their medication regimen, improve skills related to safe medication usage, and to improve patients’ confidence level in communicating with, and accessing, physicians, nurses, and pharmacists regarding their health issues and medication regimen. Prior to implementation of the small test of change, site authorization was obtained and approval was granted from Auburn University’s Institutional Review Board (IRB). Eligible participants were identified as men and women, over the age of 50, who were taking five or more medications daily. Eligible participants were given an information letter, explaining all aspects of project, and was given time to ask any questions they may have regarding the project. Participants were reassured confidentiality would be maintained throughout the project, protecting their identity and responses to the Polypharmacy Self-Assessment Questionnaire. After obtaining informed consent, participants were asked to complete the initial Polypharmacy Self-Assessment Questionnaire. The Polypharmacy Self-Assessment Questionnaire consisted of fifteen questions, assessing participants’ confidence level regarding knowledge of each of their medications’ purpose, instructions, and side effects, confidence level with communicating with physicians, nurses, and pharmacists, and confidence level in accessing their primary care physicians’ office and pharmacy. A Likert scale was used to determine confidence level, with 1= Not at all confident to 5= Extremely confident. The questionnaire also allowed participants to enter the number of medications taken, number of physicians seen, and number of pharmacies used. After completion of the initial questionnaire, enhanced medication education on each medication taken was provided to participants using the Care Notes system, and an opportunity for questions was provided. A follow-up phone call was made to each participant in 3-4 weeks, and the same Polypharmacy Self-Assessment Questionnaire was completed in order to determine the effectiveness of the medication education that was provided. BudgetThe proposed budget for the small test of change was minimal. I used my own laptop and printer. The only monetary expenditure for the project was the cost of paper and ink in for printing stamped IRB consents, pre- and post- questionnaires, and medication education that was provided to each participant. This cost totaled approximately $50.00. EvaluationEighteen participants agreed to participate in the small test of change. The tools used to evaluate outcome measures were the pre- and post- Polypharmacy Self-Assessment Questionnaire. Code sheets were made, de-identifying patients, and data from the questionnaires was entered into an Excel spreadsheet. The data from the Excel spreadsheet was then exported into the Statistical Package for the Social Sciences (SPSS) program. In order to evaluate the outcomes of the pre-education and post-education responses, descriptive statistics were used. Descriptive statistics were used for demographic variables and pre/post scores were analyzed using paired t-tests for individual questions, and sum scores were calculated to evaluate improvements in patients’ confidence level in explaining medication use, confidence in communicating with healthcare providers, and confidence level in accessing primary care physicians’ office and pharmacy. Project TimelineAn anticipated timeline was used to record activities planned and a reflective log was kept. Major components of the project were completed over a ten week period. Checkpoints were divided into two week intervals, and progress was recorded and reflected upon at each checkpoint. On the first checkpoint, arrangements were made for the first on-site visit at the primary care physician’s office, IRB approved consent forms and pre and post questionnaires were printed, and the draft for the small test of change was written. The second checkpoint consisted of the first on-site visit to the physician’s office where twelve participants were recruited for the project, and the progress of the project was discussed with the faculty advisor, Dr. Bonnie Sanderson. The third checkpoint consisted of the second on-site visit to the physician’s office to recruit more participants. Six more participants were recruited on the second on-site visit. Also during the third checkpoint, follow-up phone calls were made to the first group of participants in order to determine effectiveness of medication education, and pre-education data and post-education data from this group was entered into an Excel spreadsheet. The fourth checkpoint consisted of follow-up phone calls to the second group of participants, and pre- and post-education data from this group was added to the Excel spreadsheet. During the fourth checkpoint, the pre- and post- education data was exported from the Excel spreadsheet into the SPSS program in order to obtain descriptive statistics for demographic variables and pre- and post- education scores were analyzed using paired t-tests and sum scores were calculated. The final data was used to update and finalize the small test of change abstract. During the fifth checkpoint, the pre- and post- data was used to prepare the oral and poster presentation for the small test of change. Findings Eighteen adults consented to participate (44% female, 56% male, 100% Caucasian), ages ranged from 52 to 81, with average age of 62 (s.d. +/-7.22), average number of medications taken was 10, average number of physicians seen was 3, and average number of pharmacies used was 2. When sum scores were calculated from pre- and post- medication education, an increase in overall confidence in explaining medication use was increased from an average of 9.8 (s.d. +/- 3.07) to 11.8 (s.d. +/-2.09) (p=0.000), confidence in communicating with healthcare providers increased from an average of 11.4 (s.d.+/- 2.17) to 13.1 (s.d. +/- 1.43) (p=0.000), and confidence level in the ability to access physicians’ office and pharmacy increased from 7.8 (s.d. +/- 1.34) to 8.2 (s.d. +/- 1.27) (p=0.015) (See Figure 1).Figure 1. Overall, there was in increase in pre-education and post-education scores, suggesting that with providing enhance medication education, and encouraging patients to participate in their care, it is possible to increase patients’ confidence level and knowledge regarding their medication regimen and improve communication skills between patients and healthcare providers.Application to Overall ProjectThe small test of change proved to be beneficial in guiding the overall long-term project if resources and time were available to reach the long-term goals. The staff of the physician’s office was very helpful with the recruitment of participants. Participants were eager to become involved in the project, which allowed for an easy start and smooth progression of the project. I believe one reason participants were eager to participate is the fact the small test of change only occurred over 3-4 weeks. If the long-term project were to be conducted, the recruitment of participants who completed the study would be more challenging and difficult to maintain due to the amount of time that would be required by each participant. I found that after conducting the small test of change, the questions on the questionnaire were very broad, and often raised further questions and identified additional areas that would be beneficial in assessing if a long-term project were to be conducted. When looking at each participants’ responses to the questions, it raised questions in my mind such as what factors were involved in order for the participants to respond in the fashion they did. Therefore, if the long-term project were to be completed, I would look further into what prompted each participants’ answers, such as what particular medications patients have difficulty understanding, what factors are in place to hinder communication between patients and healthcare providers, and what factors affect patients’ access to primary care physician’s office and pharmacies. ConclusionsRoutinely evaluating patients identified with polypharmacy in the primary care setting can allow for patients to become actively involved in their care and increase their knowledge regarding the adverse events polypharmacy can entail. This EBP project concluded that by providing enhanced medication education and encouraging patient-provider communication, improvements in patients’ confidence level regarding their medication regimen, confidence level with communication between patients and healthcare providers, and confidence level regarding accessing primary care physicians’ office and pharmacies can be increased. This evidence-based practice class has been a challenging learning process over the last three semesters. It has enabled me to build from a simple PICO question, search the most up-to-date literature for the best clinical recommendations, and utilize those recommendations in order to produce a finished product of an evidence-based practice project. This process has enabled me to utilize evidence-based practice into my clinical decision making skills in my current role as a nurse, and will enable me to use it in the future as an advanced practice nurse. ReferencesAmerican Geriatrics Society 2012 Beers Criteria Update Expert Panel 2012 American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults.American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012). American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. The Journal of The American Geriatrics Society, 60(4), 616-631. doi:10.111/j.1532-5415.2012.03923Beers, M. H., Ouslander, J. G., Rollinger, I., Reuben, D. R., Brooks, J., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. Arichives of Internal Medicine, 151, 1825-1832. Bregnhoj L Thirstrup L Sonne J 2007 Prevalence of inappropriate prescribing in primary care.Bregnhoj, L., Thirstrup, S., Kristensen, M. B., Bjerrum, L., & Sonne, J. (2007). Prevalence of inappropriate prescribing in primary care. Pharmacy World Science, 29, 105-115. doi:10.1007/s11096-007-9108-0 Bushardt R L Massey E B Simpson T W Ariail J C Simpson K N 2008 Polypharmacy: Misleading but manageable.Bushardt, R. L., Massey, E. B., Simpson, T. W., Ariail, J. C., & Simpson, K. N. (2008). Polypharmacy: Misleading but manageable. Clinical Interventions in Aging, 3(2), 383-389. doi:10.1001/jama.289.19.2560201305210902371103067994Chandra A Gerwig J 2007 Addressing the Challenges Associated with Polypharmacy and Adverse Drug Events: identifying Preventive Strategies.Chandra, A., & Gerwig, J. (2007). Addressing the Challenges Associated with Polypharmacy and Adverse Drug Events: identifying Preventive Strategies. Healthcare and Public Policy, 85(7), 29-34. doi:10.3200/HTPS.85.4.59-34pp29-34 20130528191431457603932013100718200765135991620131006152121613448381Fulton M M Allen E R 2005 Polypharmacy in the elderly: A literature review.Fulton, M. M., & Allen, E. R. (2005). Polypharmacy in the elderly: A literature review. Journal of the American Academy of Nurse Practitioners, 17(4), 123-132. doi:10.1111/j.1041-2972.2005.0020.x20130721154908196770191Gallagher P Ryan C Byrne S Kennedy J O'Mahony D 2008 STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): A consensus validation.Gallagher, P., Ryan, C., Byrne, S., Kennedy, J., & O'Mahony, D. (2008). STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): A consensus validation. International Journal Clinical Pharmacological and Therapeutics, 46(2), 72-83. Retrieved June 26, 2013 from, K M Brake H Agramonte V Perfetti C 2012 Medications at transitions and clinical handoffs (MATCH) toolkit for medication reconciliationGleason, K. M., Brake, H., Agramonte, V., & Perfetti, C. (2012, August). Medications at transitions and clinical handoffs (MATCH) toolkit for medication reconciliation. Retrieved October 25, 2013, from 20131006190551199113357120130722092755461113333Haque R 2009 ARMOR: A tool to evaluate polypharmacy in elderly persons.Haque, R. (2009). ARMOR: A tool to evaluate polypharmacy in elderly persons. Annals of Long-Term Care, June, 26-30. Retrieved June 26, 2013, from 201307211457211023722291Melnyk B M Fineout-Overholt E 2011 Evidenced-Based Practice in Nursing & Healhcare. A Guide to Best PracticeMelnyk, B. M., & Fineout-Overholt, E. (2011). ARCC Evidence-Based Practice Mentors: The Key to Sustaining Evidence-Based Practice. Evidenced-Based Practice in Nursing & Healhcare. A Guide to Best Practice. (2nd ed, pp.344-351). Philadelphia: Lippincott, Williams &Wilkins. 201305211046361691295386Nobil A Garrratini S Mannucci P M 2011 Multiple diseases and polypharmacy in the elderly: Challenges for the internist of the third millenium.Nobil, A., Garrratini, S., & Mannucci, P. M. (2011). Multiple diseases and polypharmacy in the elderly: Challenges for the internist of the third millenium. Journal of Comorbidity, 1, 28-44. Retrieved June 15, 2013, from K Melville K Hanna J Gee A Chyka P 2012 Polypharmacy in the elderly: Clinical challenges in emergency practice: Part 1: Overview, etiology, and drug reactions.Prybys, K., Melville, K., Hanna, J., Gee, A., & Chyka, P. (2012). Polypharmacy in the elderly: Clinical challenges in emergency practice: Part 1: Overview, etiology, and drug reactions. Emergency Medicine Reports, 23(11), 145-153. doi:10.4326/ojn/2012.2100220130721155617434462428Riker PharmD G I Setter PharmDCDECGP S M 2012 Polypharmacy in Older Adults at Home-What it Is and What to Do About It.Riker, PharmD, G. I., & Setter, PharmD,CDE,CGP, S. M. (2012). Polypharmacy in Older Adults at Home-What it Is and What to Do About It. Home Health Care Nurse, 30(8), 474-484. doi:10.1097/NHH.0b013e31826502dd201305210724541373458147Steinman M A Landefeld C S Rosenthal G E Berthenthal D Sen S Kaboli P J 2006 Polypharmacy and prescribing quality in older people.Steinman, M. A., Landefeld, C. S., Rosenthal, G. E., Berthenthal, D., Sen, S., & Kaboli, P. J. (2006). Polypharmacy and prescribing quality in older people. Jounal of the American Geriatric Society, 54, 1516-1523. doi:10.1111/j.1532-5415.2006.00889.x 20130721190439479259252Takane A K Balignasay M Nigg C R 2013 Polypharmacy reviews among elderly populations project: Assessing needs in patient-provider communication.Takane, A. K., Balignasay, M., & Nigg, C. R. (2013). Polypharmacy reviews among elderly populations project: Assessing needs in patient-provider communication. Hawaii Journal of Medicine & Public Health, 72(1), 15-22. Retrieved June 20, 2013, from A: EVIDENCE REVIEW GRIDArticle citation in APA format Level of evidencePurpose of study/research questions Research elements: - Design- Sampling method- sample size- Brief description of interventions (if any)- outcomes measuredMajor findings relevant to project Critique of validity, bias and significance for your projectAmerican Geriatrics Society 2012 Beers Criteria Update Panel 2012 American Geriatric Society updated Beers Criteria for potentially inappropriate medication use in older adults.American Geriatrics Society 2012 Beers Criteria Update Panel (2012). American Geriatric Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of American Geriatric Society, 60(4), 616-631.631.Doi:10.1111/j.15325415.2012.03923.x 201307042156151300621510LOE: IThe purpose of this CPG was to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs); to update the previous Beers criteria using a systematic review and grading of evidence on drug-related problems and adverse drug events in older adults.Design: Clinical practice guidelinesSampling method: Purposive sampling of related articles regarding PIMs and ADEs in the older adult population that were published between December 1, 2009 and March 1, 2011. Weighting of articles selected for review was done according to a rating scheme of quality of evidence provided in each article used. Size: 2,169 unduplicated citations selected for full panel review consisting of : 446 systematic reviews; Intervention: Research panel consisting of 6 nationally recognized experts in geriatric medicine were divided into four criteria-specific groups to analyze citations relevant to their assigned criteria in order to determine which citations should be included in the final updated evidence table. A 5-point Likert scale was used for ratings of validity of medication use when combined with defined medical conditions. The panelists reviewed 38 statements regarding the use of medications when clinical data on diagnoses are not available. They also reviewed 59 scenarios of medication use that might be considered inappropriate only when any of the 17 medical conditions were known to exist. Outcomes: Recommendations for PIM use in older adults when 15 specific medical conditions are known to exist. 1) 28 criteria describing the potentially inappropriate use of medications by general populations of the elderly 2) 35 criteria defining potentially inappropriate medication use in older persons known to have any of 17 common medical conditions 3) Recommendations provided for medication use in older adults including the quality of evidence and strength for recommendations. 4) Each medication provided on table provides rationale for use or reason for avoidance. 5) Medications provided on table in groups such as organ system/therapeutic category or drug class for easy reference. Valid study producing an updated criteria for prescribing or avoiding specific medications in the older adult population. Recommendations derived from systematic reviews and RCTs (about 50%)Weaknesses: Conflicts of interest were identified within the panel selected to review citations. This included individuals who had personal ties to pharmaceutical groups of which medications manufactured by these particular groups are included in the updated Beers Criteria. The panel members who disclosed affiliations or financial interests with commercial entities were listed. Recommendations derived from observational studies (about 50%)Strengths: 1) A thorough explanation of rationale and recommendations for individual medications were provided. 2) The Beer Criteria provided a table explaining the criteria used to determine the quality of evidence and strength for recommendation for each medication that is listed on the table. Significance for my project: The clinical guidelines provided me with and up-to-date medication tool to assist me when assessing older adults’ medication lists.Fulton M M Allen E R 2005 Polypharmacy in the elderly: A literature review.Fulton, M. M., & Allen, E. R. (2005). Polypharmacy in the elderly: A literature review. Journal of the American Academy of Nurse Practitioners, 17(4), 123-132. 20130721154908196770191LOE: I 201307042148151982253314The purpose of this study was to review the body of literature addressing polypharmacy in individuals aged 60 and older to (a) determine primary care providers; definition of polypharmacy, (b explore how polypharmacy was assessed in primary care, and (c) seek tested interventions that addressed polypharmacyDesign: Systematic ReviewSampling/Sampling method: Purposive sampling of electronic bibliographic databases utilizing the search terms “polypharmacy”, ‘polypharmacy and elderly”, “polypharmacy and research”, and “multiple medications for the period of January 1991 to October 2003.Sample size: Sixteen articles Outcomes: Various assessment techniques and interventions used within the primary care setting to address polypharmacy-Multiple definitions used in the literature to define polypharmacy.-Polypharmacy has implications to healthcare costs.- The incidence of polypharmacy increases with the amount of physician visits per year.- The brown bag approach is a successful way to conduct medication reviews in the primary care setting. - Inappropriate prescribing is decreased when the Beers criteria or MAI is utilized. Validity was established due to the use of systematic review Weaknesses: 1) Multiple countries represented in this study2) Lack of consensus of the definition of polypharmacy within articles reviewed. Strengths: 1) Systematic review approach with specified criteria for inclusion. 2) Long duration of 12 years in which the study was conducted. Significance for my project: The importance of using a medication tool such as the Beers criteria and the brown bag approach for medication reviews. Gallagher P Ryan C Byrne S Kennedy J O'Mahony D 2008 STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): A consensus validation.Gallagher, P., Ryan, C., Byrne, S., Kennedy, J., & O'Mahony, D. (2008). STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): A consensus validation. International Journal Clinical Pharmacological and Therapeutics, 46(2), 72-83. 20130722092755461113333LOE: I20130704215129373453736The purpose of this study was to provide a screening tool of older persons’ prescriptions incorporating criteria for potentially inappropriate drugs and criteria for potentially inappropriate, indicated drugsDesign: Delphi process/Systematic reviewPopulation/Sampling method: Purposive sampling of an 18 member expert panelSample size- 68 STOPP criteria, and 22 START criteria. Interventions: Two rounds of questionnaires were completed in order to obtain a consensus identification of criteria for STOPP and START medications. Outcomes: consensus identification of criteria for all 22 START medications and 65 of 68 STOPP medicationsRationales provided for using or avoiding certain medications using the STOPP and START method within the older adult population. The three medications found within the STOPP method in which consensus was not obtained, the rationales were provided for prescribers to take into consideration. Validity was established due to the use of the Delphi method. Bias was eliminated due to all statements being constructed in the same manner. No conflicts of interest identified within the panelists. Weaknesses: Positive agreement pertaining to STOPP criteria of 87% and negative agreement was 13% among panelists. For the START tool, 84% agreement and 16% disagreement. Bias is not present due to no conflicts of interests among panelists identified.Strengths: 1) Delphi consensus used in order to establish content validity that was to be included into the tool2) 18 member expert panel was used 3) specific criteria was available for panelists to utilize when screening medicationsSignificance for my project: This study has significance due to the formulation of rationales for safe use or cautious use of identified medications within the START and STOPP tool. This tool will assist me in assessing patients’ medications.Steinman M A Landefeld C S Rosenthal G E Berthenthal D Sen S Kaboli P J 2006 Polypharmacy and prescribing quality in older people.Steinman, M. A., Landefeld, C. S., Rosenthal, G. E., Berthenthal, D., Sen, S., & Kaboli, P. J. (2006). Polypharmacy and prescribing quality in older people. Jounal of the American Geriatric Society, 54, 1516-1523. doi:10.1111/j.1532-5415.2006.00889.x 20130721190439479259252LOE: IV201307042201061900008083The purpose of this study was to evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients Design: Cross-sectional studySampling/Sampling Method: Purposive sampling. Individuals age 65 and older who were taking more than five medications daily were chosen from a VA medical center. Size- 196 patients Interventions: Inappropriate prescribing was addressed using the Beers criteria and the MAI. Underuse was assessed using the Assessment of Underutilization of Medications instrument.Outcomes: The presence of inappropriately prescribe or underused medications in relation to the number of medications prescribed. Total patients- n=196*One or more inappropriate medications n=128*Medication taken in violation of Beers criteria n=73*Taking medication that was ineffective, not indicated, or duplicated n=112*Medication underuse n=125*Medication underuse combined with inappropriate use n=82*Neither inappropriate or underuse n=25Weaknesses: 1) Study was only conducted among veterans at a single location. 2) Bias is present due to patients being predominantly white and male. This limits the generalizability of the findings to other populations. Strengths: 1) Large study sample of 196 patients, 2) Large study sample of 1,582 medications reviewed. 3) Only patients who could provide complete information necessary to calculate each measure was included within this study.Significance for my project- The prevalence of underuse and inappropriately prescribed medications is directly related to the number of medications prescribed. Takane A K Balignasay M Nigg C R 2013 Polypharmacy reviews among elderly populations project: Assessing needs in patient-provider communication.Takane, A. K., Balignasay, M., & Nigg, C. R. (2013). Polypharmacy reviews among elderly populations project: Assessing needs in patient-provider communication. Hawaii Journal of Medicine & Public Health, 72(1), 15-22. 20130722102024287764787LOE: IVThe purpose of this study is to evaluate the perceived issues regarding medication use, including any communication challenges with providersDesign: Observational studySampling/Sampling Method: Convenience sampling of individuals who live in Section 8 housing in Ewa Distict of O’ahu, Hawaii. Size- 21 participantsInterventions- Data was collected via a self-administered paper survey which included questions regarding knowledge of medications, and perception of patient-provider communication. Questions were obtained from the Hyperpharmacotherapy Assessment Tool regarding number of medications used, number of physicians visited, and number of pharmacies used. Outcomes- the perception of communication and overall knowledge of daily medication regimen in order to find areas in need of increased education. Participants n=21Unable to describe details regarding their medications-47.6%, side effects- 42.9%The majority, 90.5%, only use one pharmacy.Ability to describe a drug-drug interaction- 76%Ability to describe purpose of medication review- 61.9%Received an annual medication review- 28.6%Weaknesses- Small number of participants, 2) self-administered paper survey, 3) only two housing sites were chosen for the study 4) Recall bias is present due to the study being done retrospectivelyStrengths- HAT tool was used to gather information from participants.Significance for my project: The prevalence of lack of knowledge regarding medication regimens is evident in this study. Therefore, the importance of patient-provider communication and the need for routine medication reviews is evident. Bregnhoj L Thirstrup S Kristensen M B Bjerrum L Sonne J 2007 Prevalence of inappropriate prescribing in primary care.Bregnhoj, L., Thirstrup, S., Kristensen, M. B., Bjerrum, L., & Sonne, J. (2007). Prevalence of inappropriate prescribing in primary care. Pharmacy World Science, 29, 109-115. doi:10.1007/s11096-007-9108-0 20130722115208500101685LOE: IVPurpose: To describe the prevalence of inappropriate prescribing in primary care according to the MAI, and to identify the therapeutic areas most commonly involved. Design: Cross-sectional studySampling/Sampling Method: random sampling. 41 GPs randomly chose 6 patients. Size- 212 individuals, 1621 medicationsInterventions- GPs provided general medical information. Additional information related to medications that were being taken by the patient was obtained from pharmacy databases. The MAI was used to evaluate each patients’ medication regimen, while taking into consideration the patients’ medical history, of which was provided by the GP. Outcomes- the prevalence of inappropriate medications being prescribed in the primary care setting. Medications n=1621One or more inappropriate rating according to MAI n=640Patients n=212Taking medications rated as “not indicated” n=12.3%Taking medications rated as “ineffective” n=6%Given an incorrect dose n=6.7%Prescribed with incorrect instructions n=1.3%Clinically significant drug-disease/condition interaction n=3.1%Given in an unacceptable duration n=27.1%Weaknesses- 1) The clinical outcomes of the patients and the clinical significance of the ratings given from the study were not established 2) Both patients and GPs were volunteers 3) Bias is present due to GPs manually extracting the patients’ medical history and information, and the potential for changed data is present.Strengths- 1) Large number of medications reviewed, 2) Large group of GPsSignificance for my EBP project: The identification of classes of which inappropriately prescribed medications are prevalent. This will allow for increased focus when medications from these classes are identified within a patient’s medication regimen. ................
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