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The Evidence Speaks

The Evidence Speaks (November 2020)

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The Evidence Speaks Series is a recurring feature highlighting the latest in CHÉOS research. This series features summaries of select publications as well as in-depth features on the latest work from our investigators. The Series is designed to keep media and the research community up-to-date with CHÉOS’ current research results in the health outcomes field.

Lefebvre MJ, Ng PCK, Desjarlais A, McCann D, Waldvogel B,…Beaulieu M, et al. Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease PolypharmacyCan J Kidney Health Dis. 2020 Oct 29 epub ahead of print.

People who are on hemodialysis typically need to take between seven and 17 medications each day, as many of them require treatment for chronic comorbidities. Owing to the number of medicines this population takes, they are at a higher risk of adverse outcomes, drug interactions, nonadherence, and mortality related to polypharmacy. To reduce this risk, health care providers can discontinue medications that may be causing harm through a process known as deprescribing. There are some guidelines in place for this process; however, their lack of specificity and relevant safety parameters renders them unsuitable for nephrology clinicians. To improve deprescribing in nephrology, new research from CHÉOS Scientist Dr. Monica Beaulieu and a pan-Canada team set out to develop and validate deprescribing algorithms for nine medication classes in patients on hemodialysis. The study was comprised of two phases. The first phase was the development of nine algorithms using literature searches and expert opinions. The second phase was the validation of the algorithms through multiple rounds of reviewing and rating by independent experts. Each algorithm underwent three rounds of a review and subsequent revision, if necessary. If an algorithm did not achieve validation at this stage, it underwent further rounds of review and revision until it did. Six algorithms achieved content validation after three rounds, and the remaining three algorithms achieved content validation after further review. The resulting deprescribing algorithms are the first medication-specific, patient-centred guidelines to be developed and validated for patients on hemodialysis. Going forward, the team will assess these algorithms in practice across Canadian hemodialysis units.

Tai D, Li E, Liu-Ambrose T, Bansback N, Sadatsafavi M, Davis JC. Patient-Reported Outcome Measures (PROMs) to Support Adherence to Falls Prevention Clinic Recommendations: A Qualitative StudyPatient Prefer Adherence. 2020 Oct 30;14:2105-21.

Falls are common among people over the age of 65. They can lead to injury, chronic disability, and death. However, falls are preventable using a multifactorial approach, which involves a comprehensive assessment of the patient and their surrounding environment to determine risk factors and potential solutions, in appropriate clinical settings, such as Falls Prevention Clinics. While fall prevention programs conducted in these setting are effective in reducing falls, adherence to the lifestyle or exercise interventions may be limited, impacting the overall effectiveness. New research published by CHÉOS Program Head – Decision Sciences Dr. Nick Bansback and a team from UBC examined how patient-reported outcome measures (PROMs) could support adherence to fall prevention interventions in the Vancouver Falls Prevention Clinic. PROMs are self-assessments of a patient’s health, and they have the potential to improve clinical management through shared health care provider-patient communication. In this study, the patients received a medical exam to identify their personal risk factors for falls and related injuries at baseline and optional follow-ups six and 12 months later. Before receiving a fall intervention, the patients were asked to complete a PROM questionnaire, called EQ-5D-5L, and repeat this at follow-up appointments, as appropriate. A facilitator conducted interviews with 21 clinic participants to determine their views on the EQ-5D-5L PROM, how they would prefer it to be administered, how they would prefer to receive feedback, how the PROM data should be presented, and other information that they would require to improve adherence. In general, the participants had positive feedback for the questionnaire and how it could support adherence to fall prevention interventions. They found it understandable and stated that it could help providers understand a patient’s perspective and inform their treatment plan. Furthermore, they felt that the questionnaire would improve a patient’s self-awareness about the impact of their condition. Overall, participants expressed that completing the EQ-5D-5L PROM could improve patient adherence to fall prevention interventions with more productive and frequent patient-physician communication, especially the provision of clear and understandable clinical feedback, and increased patient self-awareness.

Borregaard B, Dahl JS, Lauck SB, Ryg J, Berg SK, Ekholm O, Hendriks JM, Riber LPS, Norekvål TM, Møller JE. Association between frailty and self-reported health following heart valve surgeryInt J Cardiol Heart Vasc. 2020 Nov 13;31:100671.

Frailty is common in older adults and it increases the risk of poor health outcomes such as falls, hospitalization, and mortality. Currently, there is a lack of evidence regarding whether frail patients feel their health improves after undergoing heart valve surgery to a similar extent as non-frail patients. In this study, CHÉOS Scientist Dr. Sandra Lauck joined colleagues to investigate whether there is an association between frailty and self-reported health in patients following heart valve surgery at a hospital in Denmark. Of the 288 patients assessed at discharge, 18 per cent were frail (51 patients). Frailty was associated with problems a month after surgery including muscle loss, exhaustion, weakness, slowness, and reduced activities of daily living. Of these, exhaustion, weakness, and slowness were reported to be the main problem areas for those who were assessed as frail. Overall, this study supports the association between frailty at discharge and worse self-reported health outcomes one month post-operation. This indicates there is a clinical need to not only assess frailty ahead of heart valve surgery to determine risk, as currently recommended, but also after surgery to identify potential post-operative health issues. This knowledge could inform a complex care plan for patients, which may include closer follow-up and targeted intervention to improve health outcomes and frailty status. Recognizing frailty status both before and after surgery could inform treatment and interventions, improving the overall health outcomes.