What is known and objective: Use of potentially inappropriate medications (PIMs) remains common in older adults, despite the easy availability of screening tools such as the Beers and Screening Tool of Older Person's Prescriptions (STOPP) criteria.Multiple published studies have implemented these screening tools to encourage deprescribing of PIMs, with mixed results. Little is known about the reasons behind the success or failure of these interventions, or what could be done to improve their impact. Implementation science (IS) provides a set of theories, models and frameworks to address these questions. The goal of this study was to conduct a focused narrative review of the deprescribing literature through an IS lens-to determine the extent to which implementation factors were identified and the intermediate steps in the intervention were measured. A better understanding of the existing literature, including its gaps, may provide a roadmap for future research. Methods: PubMed search from 2000-2019 using appropriate MeSH headings. Inclusion criteria: controlled trials or prospective cohort studies intended to reduce PIMs in the elderly that used hospitalizations and/or emergency department visits as outcome measures. Studies were reviewed to identify potential implementation factors (known as determinants), using the Consolidated Framework for Implementation Research (CFIR) as a guide. In addition, intermediate outcomes were extracted. Results and discussion: Of the 548 reviewed abstracts, 14 studies met the inclusion criteria and underwent detailed analysis. Of the 14 studies, 10 acknowledged potential implementation determinants that could be mapped onto CFIR. The most commonly identified determinant was the degree of pharmacist integration into the medical team (seven of 14 studies), which mapped onto the CFIR construct of 'networks and communication'. Several important CFIR constructs were absent in the reviewed literature. Intermediate measures were captured by 12 of the 14 reviewed papers, but the choice of measures was inconsistent across studies.What is new and conclusion: In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes.These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions How to cite this article: Baumgartner AD, Clark CM, LaValley SA, Monte SV, Wahler RG, Singh R. Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation? J Clin Pharm Ther. 2020;45:453-461. https ://doi.

Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

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We present a case of a 59-y-old woman who had undergone cholecystectomy and was subsequently found to have an abscess within the gallbladder fossa. A hepatobiliary scan using 99m Tc-diisopropyliminodiacetic acid demonstrated the characteristic rim sign, a photopenic defect surrounded by a rim of mildly increased activity immediately adjacent to the gallbladder fossa. The rim sign was thought to be the result of reactive inflammation in the hepatic tissue adjacent to a postoperative abscess within the gallbladder fossa.

BACKGROUND Despite making great strides in improving the treatment of disease, the minimization of iatrogenic harm continues to be a major hurdle facing the healthcare system. Potentially inappropriate medications (PIMs) in older persons represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased healthcare costs. Deprescribing attempts to combat PIMs by systematically identifying and removing high risk medications from patients’ regimens. Attempts to operationalize deprescribing, however, have had mixed results. Complex contextual factors at play make the implementation process of these new interventions difficult. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex socio-technical systems. While initially intended for the nuclear power domain and interface design, AH has been used successfully to aid healthcare redesign of numerous systems such as design of decision support tools, mobile patient monitoring applications, and a telephone triage system. OBJECTIVE The aim of this manuscript is to refine our understanding about the primary care office in relation to a patient’s medication through the development of an abstraction hierarchy. Emphasis was placed on the elements related to medication safety in order to address the challenges of deprescribing in a more effective manner. METHODS The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by two authors and later given feedback from an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreed upon AH was achieved. A means-ends analysis was performed and described for nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. RESULTS This model depicts the various components which must be balanced and coordinated to provide medical treatment with limited healthcare resources in order to ensure patient medication safety. Understanding of the complex activities that occur in a primary care office depicted in this model may define areas in which deprescribing activities can be successfully completed. CONCLUSIONS After analysis of the generalized AH, recommendations for the development of an optimized medication management system in primary care were made. Numerous means-ends relationships can be identified using AH depending on the specific needs of the user. Individual practices can utilize the AH for clinic redesign to improve prescribing and deprescribing practices.