User:Gunishakalra/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.

Link: Project Homepage and Resources


 * 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

= Polypharmacy =

How you searched for a source (search strategy – where you went to find it).
I searched PubMed through a string search of (enablers OR barriers) AND deprescribing. I applied filters for publication date of “5 years,” and article types limited to “Guideline,” “Practice Guideline,” “Review,” and “Systematic Review,” and “Meta-Analysis.” The search returned 58 results.

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

 * 1) Reeve, E., Thompson, W., & Farrell, B. (2017). Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European journal of internal medicine, 38, 3-11.
 * 2) Paque, K., Vander Stichele, R., Elseviers, M., Pardon, K., Dilles, T., Deliens, L., & Christiaens, T. (2019). Barriers and enablers to deprescribing in people with a life-limiting disease: a systematic review. Palliative medicine, 33(1), 37-48.

Why the source was chosen (what made it better than other choices).
I chose source A as it was more general in scope and included more evidence than source B, which only included evidence from 5 research articles. Additionally, source A includes perspectives from multiple healthcare practitioners, such as pharmacists and nurses, in addition to patients and physicians, whereas source B only included evidence from the latter. Source A also includes information from defining deprescribing to recommendations, and everything in between, which contextualizes the evidence within the broader evidence base.

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

 * 1) The source is a secondary source - a systematic review.
 * 2) The article is published in a journal with an impact factor of 3.2 (2017) which makes it a reliable source.
 * 3) The source was published in 2017, and is thus recent.

How do you plan to use the source for improving the article?
Deprescribing is recommended as a successful intervention strategy to reduce deprescribing, but there is a lack of information on factors that contribute to or challenge this success. I intend to use this source to add in 1-2 sentences regarding the barriers and enablers to a deprescribing strategy. I believe this will add important context to not only deprescribing interventions, but can lend to other strategies aimed at reducing polypharmacy.

Proposed Changes
Barriers faced by both physicians and patients have made it challenging to apply deprescribing strategies in practice. For physicians, these include fear of consequences of deprescribing, the prescriber’s own confidence in their skills and knowledge to deprescribe, the feasibility of deprescribing, and the complexity of having multiple providers. For patients, attitudes or beliefs about the medications, fears and uncertainties surrounding deprescribing, and influence of physicians, family, and the media are also reported barriers to deprescribing.

Rationale for Proposed Change
The article discusses deprescribing as a strategy to target polypharmacy, including strategies and tools used by physicians. However, evidence shows that the uptake of deprescribing has not been successful, and the barriers to deprescribing are not mentioned in the article. I first added in a sentence that describes both the state of deprescribing strategies in practice and why this is so, with evidence grounded in a narrative review. My second sentence describes the barriers to deprescribing from a physician perspective, using both a narrative and systematic review. My third sentence describes deprescribing barriers from a patient's perspective, including evidence from the narrative review once again.

The citations for the narrative and systematic review are below:


 * 1) Reeve, E., Thompson, W., & Farrell, B. (2017). Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European journal of internal medicine, 38, 3-11.
 * 2) Anderson, K., Stowasser, D., Freeman, C., & Scott, I. (2014). Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ open, 4(12), e006544.

Much of the evidence presented and the proposed changes are widely agreed upon in the literature; however, the specific barriers to physician deprescribing practices are described differently across the literature. In order to reconcile this, I wrote the descriptions of physician barriers as larger themes, which would be able to encompass the slightly varying definitions and descriptions found throughout the literature. In terms of patient perspectives on barriers to deprescribing, a number of studies report that patients are hypothetically willing to have a medication deprescribed. However, these studies report a hypothetical and/or a belief, whereas the focus of my proposed changes is on what deprescribing looks like in practice, as reported by patients themselves. Due to this, I chose to move forward with my position on the barriers experienced by patients when deprescribing.

Critique of Source
Although the narrative review largely used for the proposed changes encompasses a large body of evidence, there are some limitations to its use. Firstly, due to it being a narrative and not a systematic review, there were no quality assessments completed. Additionally, there were no assessments of potential bias in included studies, such as a funnel plot, which may mean only studies with favourable results were included. Further, only articles in English were included, which could also introduce bias into the review. Although there are potential sources of bias, the article provides a comprehensive and succinct overview of deprescribing; specifically, it covers literature from the very beginnings of defining deprescribing to future opportunities. As such, it is an accessible overview of the topic. However, in understanding its limitations, I have also included evidence from a systematic review, which includes both quality and risk of bias assessment. I believe the combination of the two forms a strong foundation of evidence. Feedback:

1.Well done and justified (source selection and rational for proposed change). Your proposed change adds an important point to this article that had not been raised or considered. Including the perspective of the health care providers and the patients is brilliant!