User:Doannghi.dl/sandbox

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This is place to practice clicking the "edit" button and practice adding references (via the citation button). Please see Help:My_sandbox or contact User_talk:JenOttawa with any questions.

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 * Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).


 * Talk Page Template: CARL Medical Editing Initiative/Fall 2019/Talk Page Template

Article: Polypharmacy

Assignment #2
Focus: Deprescribing as a method to reduce polypharmacy

1) How you searched for a source (search strategy – where you went to find it).


 * 1) Cochrane Review: Advanced search → “deprescribing” and “polypharmacy” → refined to January 2014 to October 2019 (last 5 years) → 4 articles generated
 * 2) PubMed: Advanced search → “deprescribing” and “polypharmacy” → refined to the past 5 years → restricted to ‘Practice Guidelines’, ‘Reviews’ and ‘Systematic Reviews’ → 423 articles generated

2) What potential sources were identified and considered (give examples of 1 or 2).


 * 1) Page, A. T., Clifford, R. M., Potter, K., Schwartz, D., & Etherton‐Beer, C. D. (2016). The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis. British Journal of Clinical Pharmacology, 82(3), 583–623. doi: 10.1111/bcp.12975
 * 2) Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Couteur, D. L., Rigby, D., … Martin, J. H. (2015). Reducing Inappropriate Polypharmacy. JAMA Internal Medicine, 175(5), 827. doi: 10.1001/jamainternmed.2015.0324

3) Why the source was chosen (what made it better than other choices).

This source included information ommitted in the Wikipedia article, such as when deprescribing is used clinically apart from palliative care. In addition, it highlights information about its feasibility and efficacy in reducing the negative effects of polypharmacy, such as mortality or hospital readmissions. Finally, it is a reliable secondary source, ie. a systematic review and meta-analysis, which included 116 studies.

4) List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria.


 * 1) It is a systematic review.
 * 2) It was published in 2016, thus is within the 7 year criteria.
 * 3) It was published in a non-predatory high quality journal (the British Journal of Clinical Pharmacology).

5) How do you plan to use the source for improving the article?


 * 1) The inclusion of deprescribing as a method to reduce polypharmacy in other clinical contexts outside of palliative care.
 * 2) Effectiveness and feasibility of deprescribing as a means to reduce the negative effects of polypharmacy.
 * 3) When should deprescribing be considered.

Assignment #3
Proposed changes

''The most common intervention in polypharmacy patients is deprescribing, which includes the identification and discontinuance of medications when the benefit no longer outweighs the harm. In elderly patients, this can commonly be done as a patient becomes more frail and treatment focus needs to shift from preventative to palliative.'' Deprescribing was also deemed feasible and effective in other settings such as residential care, communities and hospitals. This preventative measure should be considered for anyone who exhibits one of the following: (1) a new symptom or adverse event arises, (2) when the person develops an end-stage disease, (3) if the combination of drugs is risky, or (4) if the disease doesn’t get worse if the patient stops taking the drug.

Rationale for proposed changes


 * 1) Following the evidence that deprescribing is a useful intervention to mitigate polypharmacy, the authors only give examples of its use in end-of-life care. More information for deprescribing in other health contexts was needed. Thus, the attached meta-analysis was included as an evidence source to convey the use of deprescribing for other health populations. Page, A. T., Clifford, R. M., Potter, K., Schwartz, D., & Etherton‐Beer, C. D. (2016). The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis. British Journal of Clinical Pharmacology, 82(3), 583–623. doi: 10.1111/bcp.12975
 * 2) In addition, the information about the effectiveness of deprescribing was not supported in the opening sentence of this section. Therefore, the inclusion of evidence to support the use of deprescribing was needed. In addition, there is little indication on when deprescribing is useful, thus the same article was used for this information too. Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Couteur, D. L., Rigby, D., … Martin, J. H. (2015). Reducing Inappropriate Polypharmacy. JAMA Internal Medicine, 175(5), 827. doi: 10.1001/jamainternmed.2015.0324

Controversy: There was one systematic review found on Cochrane Review that highlighted findings that contradicted others. The authors had different outcome measures such as hospital readmission, potential prescribing omission, and the prescribing of potentially inappropriate medicines (PMI), in which they found only PMIs to be slightly reduced with deprescribing. I chose the direction that deprescribing is an effective intervention to reduce the negative effects of polypharmacy due to the relative strengths of the studies I chose compared to the previous one mentioned. The latter article mentioned from Cochrane only included 2 articles and their results were inconclusive. Rankin, Audrey, et al. “Interventions to Improve the Appropriate Use of Polypharmacy for Older People.” Cochrane Database of Systematic Reviews, Mar. 2018, doi:10.1002/14651858.cd008165.pub4.

Critique of Source

A source of limitation from the paper written by Scott et al. is the introduction of language bias. Only English-language studies were included in the review, neglecting the effects of socio- economics, culture and more that might arise from other papers. This could lead to a discrepancy in the evidence for the effectiveness of deprescribing for all populations. It however lends generalization power, or is useful, to the majority that may be reading Wikipedia.

Feedback:

Well done. You explained your source selection well.

I would modify a little your proposed sentence, more specifically point 4) the disease doesn't get worse if the patient stops taking the drug. If this is consistent with the source (it needs to be checked), a slightly different way of stating this would be: stopping the drug does not alter the disease trajectory.

Agata Szlanta