Assignment: Approved Clinical Questions For PICOT Development List

 Assignment: Approved Clinical Questions For PICOT Development List

 Assignment: Approved Clinical Questions For PICOT Development List

Implementing a clinical practice protocol/guideline for the management of [hypertension or disease] in [the homeless or population/clinic type]

Developing a clinical protocol to prevent [community acquired pneumonia or disease] in [vulnerable populations] in primary care

Identifying barriers to [diabetic treatment or disease or health promotion] adherence in a community primary care clinic

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An educational program to improve [influenza and/or pneumococcal or type] vaccination rates among [population]

Evaluation of an intervention protocol to improve adult vaccination rates among [older adults or population]

Primary care providers’ adherence to treatment guidelines for the management of [Type II diabetes or disease] in a [rural or type] clinic

The implementation of a clinical protocol to identify and manage [COPD or disease] in [the working poor or vulnerable population or setting]

Evaluation on implementing [smoking cessation or disease prevention/health promotion] primary clinic in long-term care

Improvement of screening rates for [sexually transmitted diseases or disease prevention targets] in a primary care clinic

Implementing a peer review process in a primary care clinic or setting

The effectiveness of implementing the [Geriatric Depression Scale or standardized assessment instrument] for the treatment and management of [depression or disease] in primary care

Evaluating the use of computer reminder systems for providers to improve treatment guideline adherence in [community care or setting]

Screening for mild cognitive impairment in a primary care setting

Primary care provider practice patterns for the treatment and management of [pain or disease] in [older adults or population]

Effectiveness of obesity management strategies in [working adults or population] with [cardiac risk factors or disease] in primary care

The impact of the Adult-Gerontology Primary Care Nurse Practitioner’s role in a healthcare home model

Identification of perceived barriers to care of [women or population] seeking treatment for [depression or disease] in primary care

Culturally sensitive care for [Asian Americans or population] seeking treatment for chronic [hypertension or disease] management in primary care

Barriers and facilitators to implementing a culturally sensitive clinical protocol in [Hispanic men or population] with [prostate cancer or disease]

Evaluation of [cost or type] outcomes of a primary care model that includes a psychiatric-mental health care nurse practitioner overlay service

Development of a [cardiac or disease/type] risk profile to identify high risk [women or population] in primary care

Effective [ADHD/Other] Screening of Children in the Primary Care Setting

Reducing BMI of Overweight and Obese [Children or population]: Evidence-Based Approach

Expedited Partner Therapy: An Option in the Treatment of [Genital Chlamydial Infection or other STI]

Effectiveness of the Use of Insulin [pens/pump]: An Analysis of the [Hispanic adult or population] Patient’s Satisfaction and Outcomes

An Effective Plan to Reduce Polypharmacy in a [State Prison or Long-term Care Facility]

The Role of Reminder Cards and Telephone Follow -Up on Office Visits on Adherence of Patient with [T2DM or other chronic disease]

Effects on A1C among Insulin Managed Diabetic Patients following an Electronic, Patient-Centered, Feedback System: An Evidence-Based Practice

The Effect of Language in the Delivery of Care in [Home Health or other community setting

The Effect of Culture and Eating Habits on [Childhood or population] Obesity in [United States or state]

The Effectiveness of [Basic Daily Monitoring or other intervention] for [Elderly or population] with Heart Failure to Reduce Hospital Readmission

Adherence to Diet and Exercise to Reduce Hyperlipidemia in [Adults or population]

Evidence-Based Practice in Management of Acute Otitis Media: Topical versus Systemic Treatments

[Walking 3x/week or Other exercise activity] for 45-minutes Reduce Blood Sugar levels in [African- Americans or population] with Type II Diabetes

Implement a [Brisk Physical Activity or other activity} to Improve BS Levels in [Women with GDM or population]?

Asthma Treatment in Pediatric Patients: Spacer versus Conventional Inhaler

Concurrent use of Probiotics during Antibiotic Therapy Reduce the Incidence of Developing Antibiotic-associated Diarrhea

The Role of Nurse Practitioner in the [Breast Cancer Risk Assessment or other Assessment] on [Hispanic Women or populations]

Brain Exercise Reduce the Cognitive Decline in Patients with [Cognitive Decline or population]

Measuring the Effectiveness of 5-2-1-0 every day to Reduce Obesity in [Children or population]

Spiritual Care: The Missing Link in Health Care Among Patients with [Advanced Cancer in Palliative Care or population]

Effectiveness of Nurse Practitioner’s Home Visits in Improving Patient Adherence in the Management of [Hypertension or population]

Nurse Practitioner’s Focus Patient Education to Prevent Complications of [Pre-eclampsia or population]

Providing Education to [Reduce Hb1Ac or Other measure] in Adherence with Current [Diabetes or other chronic disease] Guidelines

Utilization of Nurse Practitioners in the [Emergency Department or other Community Settings] on Patient Satisfaction, Provider to Patient time, and Length of Stay

Use of NP-led Triage Orders in Emergency Department for Early Patient’s Discharge

Screening of Patients with Drug-Seeking Behaviors in [Emergency Department or other Community Setting]

Developing an Education-based Approach to Increase Awareness on [Prostate Cancer or other] Screening

Reducing [HPV or other preventable disease] Incidences with Vaccination among the [Latino Population ages 11-­26 in the United States or population]

Evaluate the Effectiveness Of Post-Discharge Follow-Up Among [Congestive Heart Failure or high-risk population] Patients on Reduction of Hospital Readmission, Improve Quality Of Life, Medication Reconciliation, Self-Care Skills and Coordination of Care During Transition to Home [Other]

Primary Care Provider Practice Patterns for the Identification, Treatment, and Management of [early onset sepsis disease or other disease] in [pediatric or populations]

Evaluation on Implementing and Follow-up with Health Screening Guidelines [Colonoscopy or other Screening] in a Primary Clinic or other Community Setting

Primary Care Provider Practice Patterns for the Treatment and Management Follow-up after UC or ED visit in [older adults or population]

Barriers and facilitators to implementing a culturally sensitive clinical protocol in [refugee men or population] with [depression or other chronic disease]

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Part 2: Project Purpose Statement, Background and Significance, and PICOT Paper

Project Purpose Statement

The proposed project aims to explore the effectiveness of a comprehensive plan (NO TEARS model) in preventing polypharmacy in older adults with multi-morbidity in a long-term care facility. The NO TEARS model entails various evidence-based strategies for reviewing medications, including needs and indications, asking patients open questions, testing, and monitoring, adopting evidence-based guidelines, assessing adverse events, risk reduction, and simplification.

Background and Significance

Background

Polypharmacy is among the adverse events that compromise patient safety and well-being in long-term care facilities. Older adults in long-term care facilities often grapple with multiple healthcare concerns exacerbated by aging. Examples of prevalent health concerns in older adults include multi-morbidity, altered cognitive functioning, physical frailty, and physiological changes. More essentially, multi-morbidity exposes this at-risk population to an increased mortality risk, prolonged hospitalization, disability-adjusted life years (DALYs), and poor quality of life. Besides age-related risks, older adults are susceptible to unhealthy lifestyle behaviors, loneliness, and stress (Chen et al., 2022). These factors contribute to a high prevalence of chronic conditions, including diabetes, cardiovascular diseases (CVDs), mental and behavioral disorders, and respiratory conditions.

Amidst the need to alleviate the risk factors for multi-morbidity in older adults, the current and anticipated future increase in the aging population poses a significant threat to global and national healthcare systems. Christopher et al. (2022) posit that the global population of people aged ≥60 years will be about 22% by 2050. The aging population (>65 years) in the United States accounts for approximately 14% of the population. The anticipated increase in the population of older adults requires healthcare professionals to understand the intricacies and demands for quality, patient-centered, and evidence-based care. For instance, older adults grappling with multi-morbidity require personalized pharmacological and non-pharmacologic care interventions. According to Varghese, Ishida & Haseer Koya (2022), people aged ≥65 years in the United States account for about one-third of outpatient expenditure for medication prescriptions. Such statistics are alarming, considering the likelihood of noncompliance with medications and polypharmacy.

Older adults with multiple chronic conditions endure consistent exposure to excessive drugs, possibly resulting in adverse health outcomes. The World Health Organization [WHO] (2021) defines polypharmacy as the term that most apply when patients take five or more medications. Although taking more medications for multi-morbidity is a profound strategy for managing symptoms and preventing further complications, polypharmacy is the primary risk factor for inappropriate polypharmacy. According to the World Health Organization [WHO] (2019), inappropriate polypharmacy entails prescriptions for unnecessary medications that lack evidence-based indications and scenarios where one or more prescribed medications fail to achieve therapeutic objectives or expose the patient to a high risk of adverse drug reactions (ADRs). If left unaddressed, inappropriate polypharmacy is a profound risk factor for multiple health concerns, including life-threatening adverse effects.

The primary adverse consequences of inappropriate polypharmacy in older adults include an increased risk of death, prolonged hospitalization, adverse drug reactions, and noncompliance with pharmacologic interventions for chronic conditions (Delara et al., 2022). Due to suboptimal medication use, unaddressed polypharmacy contributes to approximately 4% of the total available costs. In this case, global healthcare systems can save $18 billion (0.3% of total global health expenditure) by implementing appropriate interventions for managing polypharmacy (World Health Organization, 2019). In the United States, inappropriate polypharmacy inflicts significant health and economic burdens that extend to about $50 billion (Delara et al., 2022). These burdens manifest through the cost of hospitalizations following adverse drug reactions, losses due to inappropriate medication use, and the cost of job losses due to premature deaths.

Besides increasing mortality risk, adverse drug reactions, and prolonged hospitalization, inappropriate polypharmacy contributes to other patient safety issues. Firstly, exposure to excessive, unnecessary medications can exacerbate various side effects, including constipation, sleeplessness, confusion, depression, loss of appetite, diarrhea, and decreased alertness (Varghese, Ishida & Haseer Koya, 2022). Healthcare professionals often overlook these side effects and may administer more medications to alleviate them, increasing people’s susceptibility to more complications associated with inappropriate polypharmacy.

Secondly, inappropriate polypharmacy exacerbates the risk of patient falls due to the side effects of medications. Zaninotto et al. (2020) posit that one-third of older adults (≥65) experience at least one fall incident annually. Life-threatening and burdensome injuries may occur in around 20% of all fall incidents. According to Dahal & Bista (2023), co-prescription of various medications may perpetuate side effects like memory loss, blurry vision, hallucinations, and confusion. Examples of these medications are anxiolytics (sedatives), narcotics, cardiovascular drugs, and anticholinergics. These side effects increase individual risk of falls and fall-related injuries.

Significance

Understanding inappropriate polypharmacy as a patient safety and health concern informs evidence-based practices for managing polypharmacy. This proposed project explores the effectiveness of a comprehensive plan in managing polypharmacy and preventing the associated adverse outcomes. The proposed intervention for this project is the NO TEARS model. The innovative aspect of this project is the aspect of using causes of potential causes of inappropriate polypharmacy to inform an evidence-based intervention for its prevention and control. According to Borodo et al. (2022), the causes of inappropriate polypharmacy are either prescriber-related factors, patient aspects, or issues in clinical settings. In this case, irrational prescription, unawareness of deprescribing protocols, and non-adherence to ethical standards for medication prescription are prescriber factors that can contribute to polypharmacy.

On the other hand, old age, multi-morbidity, and multiple prescribers can increase an individual risk of inappropriate polypharmacy. Finally, poor practice regulations, inadequate facilities, and a lack of an interdisciplinary approach to medication management are issues in clinical settings that can cause inappropriate polypharmacy (Borodo et al., 2022). As a result, it is essential to perceive polypharmacy as a multifactorial healthcare problem that requires a comprehensive management framework.

Frequent medication reviews can prevent inappropriate polypharmacy and other medication errors when considering the prescriber, patient, and clinical cause of polypharmacy. According to Shepherd (2018), medication reviews profoundly prevent adverse reactions and improve medication outcomes. One of the most profound needs for reviewing drugs administered to older adults is to deprescribe unnecessary medications that may lead to inappropriate polypharmacy. The NO TEARS tool provides comprehensive steps for reviewing medications, adjusting doses, assessing patients’ capacity to comply with drugs, identifying inappropriate medications, and deprescribing unnecessary medications. Shepherd (2018) posits that the NO TEARS tool stands for need or indication (N), open questions (O), tests (T), evidence (E), adverse effects (A), risk reduction (R), and simplification or switches (S). This model is vital in enabling healthcare professionals to organize medication reviews and prevent adverse reactions from inappropriate or unnecessary medications.

Besides enabling healthcare professionals to organize medication reviews and prevent adverse effects of inappropriate polypharmacy, the NO TEARS tool can improve medical treatment activities by inspiring medication reconciliation and proper transition of care, enhance the application of evidence-based guidelines for reviewing medication appropriateness, and allow healthcare professionals to collaborate with patients to understand issues that compromise compliance with medications (Dahal & Bista, 2023). Also, this approach supports the collaborative review of medication durations, appropriate dosing, and a discussion of the available non-pharmacologic options (Dahal & Bista, 2023). By investigating the appropriateness of the NO TEARS tool in polypharmacy management and prevention of associated adverse outcomes, the proposed project would add insights into the existing knowledge of practical tools for addressing inappropriate polypharmacy. Also, the project seeks to offer a comprehensive framework for guiding medication reviews, preventing prescription errors, and enabling the deprescribing of unnecessary medications consistent with the need to address inappropriate polypharmacy in older adults.

PICOT

PICOT Question

Among older adults with multi-morbidity in a long-term care facility (P), does the implementation of the NO TEAR tool (I), compared to no intervention (C), prevent inappropriate polypharmacy and its adverse effects (O) in six months (T)?

• P: Older adults with multi-morbidity in a long-term care facility.
• I: NO TEARS tool for medication reviews and deprescribing.
• C: No interventions.
• O: Prevention of inappropriate polypharmacy and its associated adverse effects.
• T: Six months.

References

Borodo, S. B., Jatau, A. I., Mohammed, M., Aminu, N., Shitu, Z., & Sha’aban, A. (2022). The burden of polypharmacy and potentially inappropriate medication in Nigeria: A clarion call for deprescribing practice. Bulletin of the National Research Centre, 46(1). https://doi.org/10.1186/s42269-022-00864-3

Chen, Y., Shi, L., Zheng, X., Yang, J., Xue, Y., Xiao, S., Xue, B., Zhang, J., Li, X., Lin, H., Ma, C., & Zhang, C. (2022). Patterns and determinants of multimorbidity in older adults: Study in health-ecological perspective. International Journal of Environmental Research and Public Health, 19(24), 1–15. https://doi.org/10.3390/ijerph192416756

Christopher, C., KC, B., Shrestha, S., Blebil, A. Q., Alex, D., Mohamed Ibrahim, M. I., & Ismail, N. (2022). Medication use problems among older adults at a primary care: A narrative of literature review. AGING MEDICINE, 5(2), 126–137. https://doi.org/10.1002/agm2.12203

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

Delara, M., Murray, L., Jafari, B., Bahji, A., Goodarzi, Z., Kirkham, J., Chowdhury, Z., & Seitz, D. P. (2022). Prevalence and factors associated with polypharmacy: A systematic review and meta-analysis. BMC Geriatrics, 22(1), 601. https://doi.org/10.1186/s12877-022-03279-x

Shepherd, A. B. (2018). The importance of medication reviews in a primary care setting. Nurse Prescribing, 16(6), 280–287. https://doi.org/10.12968/npre.2018.16.6.280

Varghese, D., Ishida, C., & Haseer Koya, H. (2020). Polypharmacy. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532953/

World Health Organization. (2019). Medication safety in polypharmacy (pp. 1–63). https://www.who.int/docs/default-source/patient-safety/who-uhc-sds-2019-11-eng.pdf

Zaninotto, P., Huang, Y. T., Di Gessa, G., Abell, J., Lassale, C., & Steptoe, A. (2020). Polypharmacy is a risk factor for hospital admission due to a fall: Evidence from the English longitudinal study of ageing. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09920-x