Evidence-Based Project Proposal Essay

Evidence-Based Project Proposal Essay

Evidence-Based Project Proposal Essay

Older adults in long-term care facilities grapple with multiple co-morbidities that significantly affect their health and wellness. According to Rayman et al. (2022), unaddressed co-morbidities expose older adults to adverse health outcomes, including prolonged hospitalization, mortalities, disability-adjusted life years (DALYs), and increased care costs. Besides these detrimental outcomes, co-morbidities in older adults increase the likelihood of inappropriate polypharmacy. Aggarwal, Woolford & Patel (2020) argue that treating co-morbidities with pharmacologic interventions is a profound risk factor for medication duplication and the subsequent adverse effects. Equally, older people demonstrate various characteristics that affect medications’ efficacy. For example, they are vulnerable to altered body pharmacokinetics and pharmacodynamics exacerbated by aging-related physiological changes. These factors contribute to inappropriate medication use and the detrimental consequences associated with inappropriate polypharmacy. Consequently, this evidence-based project proposal provides an overview of inappropriate polypharmacy as a significant health problem and recommends evidence-based interventions for preventing this health concern consistent with the PICOT question.

Overview of the Problem

Inappropriate polypharmacy is a multifactorial health problem that emanates from administering different medications to treat co-morbidities. According to the World Health Organization [WHO] (2021), polypharmacy is a general term applicable when patients with multiple healthcare concerns take five or more medications. On the other hand, inappropriate polypharmacy involves the subsequent prescription of unnecessary medications without considering evidence-based indications (World Health Organization, 2021). Also, scenarios where one or more medications fail to achieve the desired objectives or increase the risk of adverse drug reactions (ADRs), result in inappropriate polypharmacy.

Due to individual and healthcare professionals-associated risk factors, older adults are susceptible to inadequate polypharmacy. At the personal level, aging, the coexistence of two or more chronic conditions (multi-morbidity), altered pharmacodynamics and pharmacokinetics, and compromised adherence to medications contribute to inappropriate polypharmacy (Varghese, Ishida & Haseer Koya, 2022). Equally, healthcare professionals’ failure to consider medication indications, limited or lack of expert-led medication reviews, and inadequate follow-up plans can contribute to inappropriate polypharmacy. Finally, social determinants of health and lifestyle choices can influence appropriate polypharmacy by limiting people’s healthy aging options, including access to healthy foods, healthcare services, and housing.

Project Purpose Statement

This project explores an effective plan to reduce polypharmacy in a long-term care facility. The proposed project investigates the effectiveness of a comprehensive plan for reviewing medications and deprescribing unnecessary medications (NO TEARS) in averting the risk of inappropriate polypharmacy in older adults grappling with multiple co-morbidities in a long-term care facility. The NO TEARS medication review model recommends ensuring medication efficacy and preventing adverse side effects of unnecessary or duplicated medications. These strategies include expert-led medication reviews, consisting of needs and indications, asking patients open questions, testing, monitoring, assessing adverse side effects, reducing risks, simplifying, and applying evidence-based guidelines. If unattended, inappropriate polypharmacy can significantly affect people’s health and wellness, compromising quality care delivery.

The possible adverse health consequences of inappropriate polypharmacy emanate from the subsequent side effects of unnecessary, overprescribed, or duplicated medications for treating co-morbidities. Delara et al. (2022) argue that inappropriate polypharmacy results in adverse drug interactions, non-adherence to pharmacological interventions, prolonged hospitalization, and a high risk of premature death among victims. In the same vein, Varghese, Ishida & Haseer Koya (2022) associate inappropriate polypharmacy with various detrimental side effects of overprescribed medications, including decreased drug alertness, constipation, tiredness, confusion, loss of appetite, depression, and diarrhea. Over-prescription or co-prescription of high-risk medications, such as narcotics, cardiovascular drugs, and anticholinergic regimens, can increase patients’ risk of falls by resulting in debilitating side effects, including respiratory failure, dependency, blurry vision, hallucinations, and confusion (Dahal & Bista, 2023). A high prevalence of patient falls results in fractures, deaths, and the associated economic burden. As a result, it is essential to apply evidence-based practice to prevent inappropriate polypharmacy and its associated adverse health outcomes.

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Background and Significance

The far-reaching adverse effects of inappropriate polypharmacy in older adults increase the demand for evidence-based medication management practices. According to Christopher et al. (2022), the global population of older adults (≥60 years) will increase by about 22% by 2050. In the United States, people aged ≥65 years account for about 14% of the country’s population. Despite only accounting for approximately 14% of the US population, older people are responsible for about one-third of outpatient expenditure for medication prescriptions (Varghese, Ishida & Haseer Koya, 2022). Such statistics signify that this population is susceptible to polypharmacy and the subsequent inappropriate polypharmacy.

Notably, inappropriate polypharmacy in older adults increases the risk of death, prolonged hospitalization, non-compliance to medication, and adverse drug interactions. Besides these detrimental health outcomes, the economic burden of inappropriate polypharmacy is massive. The World Health Organization [WHO] (2023) estimates that global healthcare systems can prevent losses of about 18 billion (0.3% of global health expenditure) by managing polypharmacy. The United States endures burdensome economic consequences of polypharmacy that emanate from various variables, including the cost of hospitalizations, losses associated with inappropriate medication use, and the cost of employment loss due to premature deaths and disabilities. According to Delara et al. (2022), losses from these aspects amount to approximately $50 billion. When considering the overarching need to ensure the “quadruple aim” in healthcare, healthcare professionals and health entities should implement proven interventions for ensuring appropriate polypharmacy and averting the adverse outcomes of inappropriate polypharmacy.

The proposed project recommends innovative interventions for reviewing medications and deprescribing unnecessary medications to avert their side effects. According to Dahal & Bista (2023), the NO TEARS medication review is among the highly-recommended medication review tools for preventing adverse medication outcomes. This model emphasizes various steps and components for ensuring medication compliance and preventing side effects. These components include the need for drug indications and reviews on appropriate dosing, duration, and available non-pharmacologic options, asking open-ended questions to patients to ascertain their understanding of medication adherence, and testing and monitoring patients’ conditions consistent with clinical findings and labs (Dahal & Bista, 2023). Further, the tool applies evidence-based guidelines for reviewing medication appropriateness, regular assessment of potential adverse events, risk reduction and prevention, and medication reconciliation to simplify medical treatment options (Dahal & Bista, 2023). Finally, the NO TEARS tool recommends proper transition of care management and coordination to simplify medication and prevent potential adverse effects.

The NO TEARS medication review tool is consistent with other emerging models for preventing polypharmacy, including the Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP), Medication Appropriateness Index (MAI), and the Updated American Geriatrics Society (AGS) Beers Criteria. Adequate incorporation of the NO TEARS model in medication reviews and deprescribing practices can result in positive health outcomes consistent with the overarching objective of preventing inappropriate polypharmacy. These positive outcomes include enabling healthcare professionals to organize medication reviews and avert the potential side effects of co-prescribed medications, inspiring the subsequent collaboration between healthcare professionals and patients in medications, and adherence to the rights of medication administration, including correct dosages, timing, and documentation. Also, this tool allows healthcare professionals to apply evidence-based interventions for medication simplification, including medication reconciliation and proper transition of care coordination and management (Dahal & Bista, 2023). Consequently, it is an ideal model for ensuring appropriate polypharmacy and improving the health outcomes of older adults with multiple co-morbidities.

PICOT-Formatted Clinical Project Question (s)

Among older adults with multiple co-morbidities in a long-term care facility (P), does the implementation of the NO TEARS medication review model/tool (I), compared to no medication reviews (no intervention) (C), prevent inappropriate polypharmacy and its associated adverse effects (O) in six months (T)?

PICOT question breakdown

• P: Older adults with multiple co-morbidities in a long-term care facility
• I: NO TEARS tool for medication reviews and deprescribing unnecessary or duplicated medications.
• C: No medication reviews and deprescribing (no intervention)
• O: Prevention of inappropriate polypharmacy and its associated adverse health outcomes
• T: Six months.

Literature Review

Identifying and selecting ideal scholarly evidence for the foreground question is a profound step of evidence-based practice (EBP). When locating external evidence sources that explore the effectiveness of the NO TEARS tool in preventing inappropriate polypharmacy, various keywords, and subtitles formed the basis of a comprehensive search strategy. These keywords and search terms include deprescribing unnecessary medications, NO TEARS tool and polypharmacy, medication reviews and polypharmacy, polypharmacy prevention, medication reviews, and deprescribing. These keywords facilitated access to electronic databases, including PubMed, BMC, and PLOS Medicine. The selected articles satisfied various elements of inclusion criteria, including publication data (2018-2023), consistency with the PICOT question, and research design (quantitative and qualitative). The search process narrowed to five scholarly articles satisfying the eligibility criteria.

Summaries of Research Studies

The selected scholarly articles provided insights into the effectiveness of medication reviews and deprescribing in preventing inappropriate polypharmacy. Although information gaps are evident in the correct scholarly literature regarding the effectiveness of the NO TEARS tool in preventing inappropriate polypharmacy, these quantitative and qualitative studies reported consistent findings on the rationale for medication reviews and deprescribing in inappropriate polypharmacy prevention. Verdoorn et al. (2019) conducted a randomized controlled trial involving 584 participants from 35 community pharmacies in the Netherlands to investigate the effects of patient-centered clinical mental reviews. The study revealed that the number of health problems significantly decreased by 12% in the intervention group compared to the control group (p=.024). These findings were consistent with the study’s hypothesis that medication reviews focused on patients’ health goals and preferences could improve their well-being.

In a systematic review and meta-analysis of randomized and cluster randomized controlled trials, Bloomfield et al. (2023) revealed findings that supported medication reviews and deprescribing across the reviewed 47 studies. The reviewed studies associate medication reviews and deprescribing with various positive health outcomes, including fall prevention, reduction of premature deaths, and hospitalizations. In another systematic review of prospective interventional cohort and pre-and-post-comparison studies, Ibrahim et al. (2021) revealed consistent findings across the six reviewed studies. These studies associate medication deprescribing with positive outcomes like reduced falls, delirium, fractures, and depression.

Qualitative studies by Lee et al. (2020) and Kurczewska-Michalak et al. (2021) support the rationale for preventing inappropriate polypharmacy through medication reviews and deprescribing. According to Lee et al. (2020), comprehensive medication reviews improve shared decision-making, support patient education, and promote the utilization of evidence-based guidelines. Similarly, Kurczewska-Michalak et al. (2021) argue that medication reviews with follow-up, validated screening tools like STOPP/START, and collaborative physician-pharmacist medication therapy management are evidence-based practices for preventing inappropriate polypharmacy in older adults. These findings can justify the effectiveness of medication review and deprescribing in preventing polypharmacy.

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Critical Appraisal of Literature

The reviewed scholarly studies satisfy various elements of credible evidence sources, including relevance, currency (2018-2023), purpose, reliability, and accuracy. For instance, quantitative studies by Verdoorn et al. (2021), Bloomfield et al., 2020), and Ibrahim et al. (2021) reported various design-related strengths, including the randomization of participants, application of pre-tests and t-tests to assess inter-group differences and blinding to reduce biases. Similarly, qualitative studies by Lee et al. (2020) and Kurczewska-Michalak et al. (2021) demonstrated various strengths, including a comprehensive review of literature, grey literature considerations, and all search iterations documentation.

Despite the reported strengths of the selected studies, they did not explore the effectiveness of the NO TEARS tool in preventing polypharmacy. This aspect represents the existing gap in the current scholarly literature. Also, these studies reported various limitations, including language restrictions (Kurczewska-Michalak et al., 2021; Lee et al., 2021; Bloomfield et al., 2020), lack of standardized search terms and definitions (Lee et al., 2021), limitations in performance settings and guidelines (Verdoorn et al., 2019), and limited considerations of grey literature (Ibrahim et al., 2021). These limitations significantly affect the findings’ accuracy, reliability, generalizability, and transferability.

An Evidence-Based Standard

Based on the reviewed literature, it is valid to contend that healthcare professionals and organizations can prevent inappropriate polypharmacy and its associated adverse effects by implementing the following evidence-based practices; collaborative medication reviews by using recommended tools, deprescribing unnecessary medications, and educating patients on treatment options (Kim & Parish, 2021). Although medication reviews and deprescribing are ideal for preventing the associated side effects of co-prescribed medications, patient empowerment through education, engagement, and follow-up activities is central to improved medication adherence and utilization. According to Kim & Parish (2021), healthcare professionals are responsible for initiating open and effective communication, engaging patients in deprescribing decisions, and educating patients and families about treatment options. Healthcare professionals should simplify medical instructions and comply with ethical standards when engaging patients in medication reviews and deprescribing decisions. These standards include safeguarding patient autonomy, ensuring beneficence, averting harm, and promoting justice.

Implications

The proposed project emphasizes the importance of medication reviews and deprescribing in preventing inappropriate polypharmacy. Amidst the existing gap in knowledge regarding the effectiveness of the NO TEARS tool in preventing inappropriate polypharmacy, this project focuses on evidence-based recommendations for patient-centered medication reviews and deprescribing practices. Therefore, it is consistent with the current scholarly literature and seeks to address the knowledge gap. By implementing the project, healthcare professionals would profoundly address the problem of inappropriate polypharmacy and improve medication safety in older adults with multiple co-morbidities.

Conclusion

Older adults with multiple co-morbidities are susceptible to inappropriate polypharmacy and its associated adverse outcomes. The current scholarly literature supports patient-centered medication reviews and deprescribing as ideal strategies for preventing inappropriate polypharmacy. Although there is a gap in knowledge regarding the effectiveness of the NO TEARS tool in preventing polypharmacy, the reviewed literature reveals consistent findings on the rationale for evidence-based medication review tools and descriptions in addressing this problem. Therefore, it is essential to apply evidence-based medication reviews and deprescribing decisions in promoting appropriate polypharmacy in older adults in long-term care facilities.

References

Aggarwal, P., Woolford, S. J., & Patel, H. P. (2020). Multi-Morbidity and polypharmacy in older people: Challenges and opportunities for clinical practice. Geriatrics, 5(4), 85. https://doi.org/10.3390/geriatrics5040085

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

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

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

Kim, J., & Parish, A. L. (2021). Nursing: Polypharmacy and medication management in older adults. Clinics in Integrated Care, 8, 100070. https://doi.org/10.1016/j.intcar.2021.100070

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

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

Rayman, G., Akpan, A., Cowie, M., Evans, R., Patel, M., Posporelis, S., & Walsh, K. (2022). Managing patients with comorbidities: Future models of care. Future Healthcare Journal, 9(2), 101–105. https://doi.org/10.7861/fhj.2022-0029

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

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

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

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The purpose of the signature assignment is for students to apply the research and EBP concepts learned in this course and develop a framework for the initial steps of the capstone project. The assignment allows the student to initiate the steps for planning, researching and developing an evidence-based practice intervention project proposal. This formal paper will include and expand upon work completed thus far in prior assignments.

On or before Day 7, of week eight each student will submit his or her final proposal paper to the week eight assignment link in D2L. This formal paper will include and expand upon work completed thus far in prior assignments.

Essential Components of the Final Project Proposal will include:

Introduction– Provide an introduction to your topic or project. The introduction gives the reader an accurate, concrete understanding what the project will cover and what can be gained from implementation of this project.

Overview of the Problem – Discuss the problem, why the problem is worth exploring and the potential contribution of the proposed project to the discipline of nursing.

Project Purpose Statement – Provide a declarative sentence or two which summarizes the specific topic and goals of the project.

Background and Significance – State the importance of the problem and emphasize what is innovative about your proposed project. Discuss the potential impact of your project on your anticipated results to the betterment of health and/or health outcomes.

PICOT formatted Clinical Project Question(s)– Provide the Population, Intervention, Comparison, Expected Outcomes and Timeframe for the proposed project.

Literature Review – Provide the key terms used to guide a search for evidence and discuss at least five (5) summaries of relevant, credible, recent, evidence-based research studies to support the project proposal.

Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and what gaps in evidence were found from the appraisal of evidence-based research studies.

Develop an EBP Standard – Develop an EBP standard integrating ethical reasoning. Describe two to three interventions (or a bundle of care) from the evidence and discuss how individual patient preferences or the preferences of others will be considered.

Implications – Summarize the potential contributions of the proposed project for nursing research, education and practice.