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Review

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population – Public Health Implications

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Pages 1007-1022 | Published online: 20 Oct 2020

References

  • O’Mara G. Could ACE inhibitors and particularly ARBs increase susceptibility to COVID-19 infection? BMJ. 2020;368:m406.
  • Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. J Comorb. 2011;1:28–44. doi:10.15256/joc.2011.1.4
  • Prithviraj GK, Koroukian S, Margevicius S, Berger NA, Bagai R, Owusu C. Patient characteristics associated with polypharmacy and inappropriate prescribing of medications among older adults with cancer. J Geriatr Oncol. 2012;3(3):228–237. doi:10.1016/j.jgo.2012.02.005
  • Zelko E, Klemenc-Ketis Z, Tusek-Bunc K. Medication adherence in elderly with polypharmacy living at home: a systematic review of existing studies. Mater Sociomed. 2016;28(2):129–132. doi:doi.10.5455/msm.2016.28.129-132.
  • Herr M, Sirven N, Grondin H, Pichetti S, Sermet C. Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population. Eur J Clin Pharmacol. 2017;73(9):1165–1172. doi:10.1007/s00228-017-2276-5.
  • Stocks SJ, Kontopantelis E, Akbarov A, Rodgers S, Avery AJ, Ashcroft DM. Examining variations in prescribing safety in UK general practice: cross-sectional study using the clinical practice research datalink. BMJ. 2015;351:h5501. doi:10.1136/bmj.h5501
  • Hanlon P, Nicholl BI, Jani BD, et al. Examining patterns of multimorbidity, polypharmacy, and risk of adverse drug reactions in chronic obstructive pulmonary disease: a cross-sectional UK Biobank study. BMJ Open. 2018;8(1):e018404. doi:10.1136/bmjopen-2017-018404
  • Dookeeram D, Bidaisee S, Paul JF, et al. Polypharmacy and potential drug-drug interactions in emergency department patients in the Caribbean. Int J Clin Pharm. 2017;39(5):1119‐27. doi:10.1007/s11096-017-0520-9
  • Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 19992012. JAMA. 2015;314(17):1818–1831. doi:10.1001/jama.2015.13766
  • Hovstadius B, Hovstadius K, Astrand B, Petersson G. Increasing polypharmacy - an individual-based study of the Swedish population 20052008. BMC Clin Pharmacol. 2010;10:16. doi:10.1186/1472-6904-10-16
  • Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383–389. doi:10.2147/cia.s2468
  • Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230. doi:10.1186/s12877-017-0621-2
  • Duerden M, Avery T, Payne R Polypharmacy and medicines optimization: making it safe and sound. London: the King’s Fund; 2013. Available from http://www.volgmed.ru/uploads/files/2014-12/35099-prilozhenie_1-3_k_informacionnomu_pismu_2.pdf. [Accessed September 10, 2020.]
  • Friend DG. Polypharmacy; multiple-ingredient and shotgun prescriptions. N Engl J Med. 1959;260(20):1015–1018. doi:10.1056/NEJM195905142602005
  • De Las Cuevas C, Sanz EJ. Polypharmacy in psychiatric practice in the Canary Islands. BMC Psychiatry. 2004;4:18. doi:10.1186/1471-244X-4-18
  • Riker GI, Setter SM. Polypharmacy in older adults at home: what it is and what to do about it–implications for home healthcare and hospice. Home Healthc Nurse. 2012;30(8):474–487. doi:10.1097/NHH.0b013e31826502dd
  • Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. The rising tide of polypharmacy and drug-drug interactions: population database analysis 19952010. BMC Med. 2015;13:74. doi:10.1186/s12916-015-0322-7
  • Walckiers D, Van der Heyden J, Tafforeau J. Factors associated with excessive polypharmacy in older people. Arch Public Health. 2015;73:50. doi:10.1186/s13690-015-0095-7
  • Moriarty F, Hardy C, Bennett K, Smith SM, Fahey T. Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study. BMJ Open. 2015;5(9):e008656. doi:10.1136/bmjopen-2015-008656
  • Ong SM, Lim YMF, Sivasampu S, Khoo EM. Variation of polypharmacy in older primary care attenders occurs at the prescriber level. BMC Geriatr. 2018;18(1):59. doi:10.1186/s12877-018-0750-2
  • Beuscart JB, Petit S, Gautier S, et al. Polypharmacy in older patients: identifying the need for support by a community pharmacist. BMC Geriatr. 2019;19(1):277. doi:10.1186/s12877-019-1276-y
  • Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–351. doi:10.1016/j.amjopharm.2007.12.002
  • Aronson JK. Polypharmacy, appropriate, and inappropriate. Br J Gen Pract. 2006;56(528):484–485.
  • Aronson JK. In defense of polypharmacy. Br J Clin Pharmacol. 2004;57:119–120. doi:10.1111/j.1365-2125.2004.02067.x
  • Aronson JK. Rational prescribing, appropriate prescribing. Br J Clin Pharmacol. 2004;57:229–230. doi:10.1111/j.1365-2125.2004.02090.x
  • Dagli RJ, Sharma A. Polypharmacy: a global risk factor for elderly people. J Int Oral Health. 2014;6(6):i–ii.
  • Molokhia M, Majeed A. Current and future perspectives on the management of polypharmacy. BMC Fam Pract. 2017;18(1):70. doi:10.1186/s12875-017-0642-0
  • Gutiérrez-Valencia M, Izquierdo M, Cesari M, Casas-Herrero Á, Inzitari M, Martínez-Velilla N. The relationship between frailty and polypharmacy in older people: A systematic review. Br J Clin Pharmacol. 2018;84(7):1432–1444. doi:10.1111/bcp.13590
  • Porter B, Arthur A, Savva GM. How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults? A cohort study. BMJ Open. 2019;9(5):e026171. doi:10.1136/bmjopen-2018-026171
  • Kwan D, Farrell B. Polypharmacy: optimizing medication use in elderly patients. Can Geriatr J. 2014;4(1):21–27.
  • Pappa E, Kontodimopoulos N, Papadopoulos AA, Tountas Y, Niakas D. Prescribed-drug utilization and polypharmacy in a general population in Greece: association with sociodemographic, health needs, health-services utilization, and lifestyle factors. Eur J Clin Pharmacol. 2011;67(2):185–192. doi:10.1007/s00228-010-0940-0
  • Charlesworth CJ, Smit E, Lee DS, Alramadhan F, Odden MC. Polypharmacy Among Adults Aged 65 Years and Older in the United States: 19882010. J Gerontol, a Biol Sci Med Sci. 2015;70(8):989–995. doi:10.1093/gerona/glv013
  • Wong H, Heuberger R, Logomarsino J, Hewlings S. Associations between alcohol use, polypharmacy, and falls in older adults. Nurs Older People. 2016;28(1):30–36.
  • Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr Med. 2012;28(2):159–172. doi:10.1016/j.cger.2012.01.001
  • Carmona-Torres JM, Cobo-Cuenca AI, Recio-Andrade B, Laredo-Aguilera JA, Martins MM, Rodríguez-Borrego MA. Prevalence and factors associated with polypharmacy in the older people: 20062014. J Clin Nurs. 2018;27(1516):2942–2952. doi:10.1111/jocn.14371
  • Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57–65. doi:10.1517/14740338.2013.827660
  • Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol. 2010;69(5):543–552. doi:10.1111/j.1365-2125.2010.03628.x
  • Bradley MC, Fahey T, Cahir C, et al. Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database. Eur J Clin Pharmacol. 2012;68(10):1425–1433. doi:10.1007/s00228-012-1249-y
  • Aitken M, Gorokhovich L. Advancing the Responsible Use of Medicines: Applying Levers for Change. Parsippany (NJ): IMS Institute for Healthcare Informatics; 2012.
  • Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–834. doi:10.1001/jamainternmed.2015.0324
  • Wang R, Chen L, Fan L, et al. Incidence and effects of polypharmacy on clinical outcome among patients aged 80+: a five-year follow-up study. PLoS One. 2015;10(11):e0142123. doi:10.1371/journal.pone.0142123
  • Tiihonen J, Suokas JT, Suvisaari JM, Haukka J, Korhonen P. Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia. Arch Gen Psychiatry. 2012;69(5):476‐83. doi:10.1001/archgenpsychiatry.2011.1532
  • Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs Aging. 2013;30(5):285‐307. doi:10.1007/s40266-013-0064-1
  • Sönnichsen A, Trampisch US, Rieckert A, et al. Polypharmacy in chronic diseases-reduction of inappropriate medication and adverse drug events in older populations by electronic decision support (PRIMA-eDS): study protocol for a randomized controlled trial. Trials. 2016;17:57. doi:10.1186/s13063-016-1177-8
  • Uchida M, Suzuki S, Sugawara H, et al. A nationwide survey of hospital pharmacist interventions to improve polypharmacy for patients with cancer in palliative care in Japan. J Pharm Health Care Sci. 2019;5:14. doi:10.1186/s40780-019-0143-5
  • Alarcón T, Bárcena A, González-Montalvo JI, Penãlosa C, Salgado A. Factors predictive of outcome on admission to an acute geriatric ward. Age Ageing. 1999;28(5):429‐32. doi:10.1093/ageing/28.5.429
  • Unutmaz GD, Soysal P, Tuven B, Isik AT. Costs of medication in older patients: before and after comprehensive geriatric assessment. Clin Interv Aging. 2018;13:607‐13. doi:10.2147/CIA.S159966
  • Flaherty JH, Perry HM 3rd, Lynchard GS, Morley JE. Polypharmacy and hospitalization among older home care patients. J Gerontol a Biol Sci Med Sci. 2000;55(10):M554–M559. doi:10.1093/gerona/55.10.m554
  • Franchi C, Marcucci M, Mannucci PM, et al. Changes in clinical outcomes for community-dwelling older people exposed to incident chronic polypharmacy: a comparison between 2001 and 2009. Pharmacoepidemiol Drug Saf. 2016;25(2):204–211. doi:10.1002/pds.3938
  • Alsuwaidan A, Almedlej N, Alsabti S, et al. A comprehensive overview of polypharmacy in elderly patients in Saudi Arabia. Geriatrics. 2019;4(2):36. doi:10.3390/geriatrics4020036
  • Zumla A, Hui DS, Perlman S. Middle East respiratory syndrome. Lancet. 2015;386(9997):995–1007. doi:10.1016/S0140-6736(15)60454-8
  • Chan-Yeung M, Xu RH. SARS: epidemiology. Respirology. 2003;8(Suppl):S9–S14. doi:10.1046/j.1440-1843.2003.00518.x
  • Wastesson JW, Morin L, Tan ECK, Johnell K. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opin Drug Saf. 2018;17(12):1185–1196. doi:10.1080/14740338.2018.1546841
  • Mahase E. China coronavirus: what do we know so far? BMJ. 2020;368:m308. doi:10.1136/bmj.m308
  • Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003;289(2):179–186. doi:10.1001/jama.289.2.179
  • Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020:e201585. doi:10.1001/jama.2020.1585.
  • Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol. 2020;92(4):441–447. doi:10.1002/jmv.25689
  • Aron J, Muellbauer J A pandemic primer on excess mortality statistics and their comparability across countries. Our World in Data; 2020. Available from https://ourworldindata.org/covid-excess-mortality. [Accessed July 11, 2020.]
  • Coronavirus Disease 2019 (COVID-19). Daily Data Summary; 2020. Available from https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-daily-data-summary-deaths-05132020-1.pdf. [Accessed July 11, 2020.]
  • World Health Organization. Global Health and Aging. Geneva: WHO; 2011. Available athttps://www.who.int/ageing/publications/global_health.pdf?ua=1. Accessed 21 June 2020.
  • Rich MW. Heart failure in the 21st century: a cardiogeriatric syndrome. J Gerontol a Biol Sci Med Sci. 2001;56(2):M88‐M96. doi:10.1093/gerona/56.2.m88
  • Boumendil A, Maury E, Reinhard I, Luquel L, Offenstadt G, Guidet B. Prognosis of patients aged 80 years and over admitted in medical intensive care unit. Intensive Care Med. 2004;30(4):647‐54. doi:10.1007/s00134-003-2150-z
  • Chiatti C, Bustacchini S, Furneri G, et al. The economic burden of inappropriate drug prescribing, lack of adherence and compliance, adverse drug events in older people: a systematic review. Drug Saf. 2012;35(Suppl 1):73–87. doi:10.1007/BF03319105
  • Back DJ, Marzolini C. The challenge of HIV treatment in an era of polypharmacy. J Int AIDS Soc. 2020;23:e25449. doi:10.1002/jia2.25449
  • Al Ameri MN, Makramalla E, Albur U, Kumar A, Rao P. Prevalence of polypharmacy in the elderly: implications of age, gender, co-morbidities, and drug interactions. SOJ Pharm Sci. 2014;1(3):1–7.
  • Fukuba N, Nishida M, Hayashi M, et al. The relationship between polypharmacy and hospital-stay duration: a retrospective study. Cureus. 2020;12(3):e7267. doi:10.7759/cureus.7267
  • Back D, Marzolini C, Hodge C, et al. COVID-19 treatment in patients with co-morbidities: awareness of drug-drug interactions. Br J Clin Pharmacol. 2020. doi:10.1111/bcp.14358
  • Hung IF, Zhang AJ, To KK, et al. Unexpectedly higher morbidity and mortality of hospitalized elderly patients associated with rhinovirus compared with influenza virus respiratory tract infection. Int J Mol Sci. 2017;18(2):259. doi:10.3390/ijms18020259
  • Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med. 2005;352(17):1749‐59. doi:10.1056/NEJMoa043951
  • Elliot AJ, Fleming DM. Influenza and respiratory syncytial virus in the elderly. Expert Rev Vaccines. 2008;7(2):249‐58. doi:10.1586/14760584.7.2.249
  • Clayville LR. Influenza update: a review of currently available vaccines. P T. 2011;36(10):659‐84.
  • Goel MK, Goel M, Khanna P, Mittal K. Pandemic influenza A (H1N1) 2009 vaccine: an update. Indian J Med Microbiol. 2011;29(1):13‐18. doi:10.4103/0255-0857.76517
  • Center for Disease Control and Prevention. People 65 years and older & influenzas. National Center for Immunization and Respiratory Diseases (NCIRD); 2019. Available from: https://www.cdc.gov/flu/highrisk/65over.htm. (Accessed May 15, 2020.)
  • Haber N, Khelili D, Martineau D, Dekimeche S, Szekely C, Lebon P. Delay in diagnosis of influenza virus in an elderly hospitalized patient: a fatal outcome. Clin Med Insights Case Rep. 2012;5:5‐8. doi:10.4137/CCRep.S8460
  • Régis C, Voirin N, Escuret V, et al. Five years of hospital-based surveillance of influenza-like illness and influenza in a short-stay geriatric unit. BMC Res Notes. 2014;7:99. doi:10.1186/1756-0500-7-99
  • Ison MG. Influenza in hospitalized adults: gaining insight into a significant problem. J Infect Dis. 2009;200(4):485‐88. doi:10.1086/600384
  • van den Dool C, Hak E, Wallinga J, van Loon AM, Lammers JW, Bonten MJ. Symptoms of influenza virus infection in hospitalized patients. Infect Control Hosp Epidemiol. 2008;29(4):314‐19. doi:10.1086/529211
  • Fried TR, Vaz Fragoso CA, Rabow MW. Caring for the older person with chronic obstructive pulmonary disease. JAMA. 2012;308(12):1254‐63. doi:10.1001/jama.2012.12422
  • Wilhelm M. Influenza in older patients: a call to action and recent updates for vaccinations. Am J Manag Care. 2018;24(2 Suppl):S15‐S24.
  • Brundage JF, Shanks GD. Deaths from bacterial pneumonia during 191819 influenza pandemic. Emerg Infect Dis. 2008;14(8):1193‐99. doi:10.3201/eid1408.071313
  • Shanks GD, Mackenzie A, McLaughlin R, et al. Mortality risk factors during the 191819 influenza pandemic in the Australian army. J Infect Dis. 2010;201(12):1880‐9. doi:10.1086/652868
  • Zhou H, Thompson WW, Viboud CG, et al. Hospitalizations associated with influenza and respiratory syncytial virus in the United States, 19932008. Clin Infect Dis. 2012;54(10):1427‐36. doi:10.1093/cid/cis211
  • Palekar RS, Rolfes MA, Arriola CS, et al. Burden of influenza-associated respiratory hospitalizations in the Americas, 20102015. PLoS One. 2019;14(9):e0221479. doi:10.1371/journal.pone.0221479
  • Amawi H, Abu Deiab GI, An Aljabali AA. COVID-19 pandemic: an overview of epidemiology, pathogenesis, diagnostics, and potential vaccines and therapeutics.. Ther Deliv. 2020;11((4)):245‐68. doi:10.4155
  • Center for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19), people who are at higher risk: older Adults. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html. (Accessed June 21, 2020.)
  • Bonanad C, García-Blas S, Tarazona-Santabalbina FJ, et al. Coronavirus: la emergencia geriátrica de 2020. Documento conjunto de la sección de cardiología geriátrica de la sociedad española de cardiología y la sociedad española de geriatría y gerontología [coronavirus: the geriatric emergency of 2020. Joint document of the geriatric cardiology section of the spanish society of cardiology and the spanish society of geriatrics and gerontology]. Rev Esp Cardiol. 2020. doi:10.1016/j.recesp.2020.03.027
  • Li W, Ding C, Yin S. Severe pneumonia in the elderly: a multivariate analysis of risk factors. Int J Clin Exp Med. 2015;8(8):12463‐75.
  • Simonetti AF, Viasus D, Garcia-Vidal C, Carratalà J. Management of community-acquired pneumonia in older adults. Ther Adv Infect Dis. 2014;2(1):3‐16. doi:10.1177/2049936113518041
  • World Health Organization. Regional office for the western pacific. Calibrating long-term non-pharmaceutical interventions for COVID-19: principles and facilitation tools. Manila: WHO. Regional Office for the Western Pacific; (‎2020)‎. Available from: https://apps.who.int/iris/handle/10665/332099. License: CC BY-NC-SA 3.0 IGO. (Accessed June 21, 2020.)
  • Hamid S, Mir MY, Rohela GK. Novel coronavirus disease (COVID-19): a pandemic (epidemiology, pathogenesis, and potential therapeutics). New Microbes New Infect. 2020;35:100679. doi:10.1016/j.nmni.2020.100679
  • World Health Organization. Regional Office for Europe. Statement- Older people are at higher risk from COVID-19, but all must act to prevent community spread; 2020. Avaialablr from:. https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/statements/statement-older-people-are-at-highest-risk-from-covid-19,-but-all-must-act-to-prevent-community-spread.
  • Fischer F, Raiber L, Boscher C, Winter MH. COVID-19 and the elderly: who cares? Front Public Health. 2020;8:151. doi:10.3389/fpubh.2020.00151
  • Koff WC, Williams MA. Covid-19 and immunity in aging populations - a new research agenda. N Engl J Med. 2020;383:804–805. doi:10.1056/NEJMp2006761
  • Guan WJ, Liang WH, Zhao Y, et al. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J. 2020;55(5):2000547. doi:10.1183/13993003.00547-2020
  • Li X, Ma X. Acute respiratory failure in COVID-19: is it “typical” ARDS? Crit Care. 2020;24(198). doi:10.1186/s13054-020-02911-9
  • Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;46(5):846‐8. doi:10.1007/s00134-020-05991-x
  • Singhal TA. Review of Coronavirus Disease-2019 (COVID-19). Indian J Pediatr. 2020;87(4):281‐6. doi:10.1007/s12098-020-03263-6
  • Greenland JR, Michelow MD, Wang L, London MJ. COVID-19 Infection: implications for perioperative and critical care physicians. Anesthesiology. 2020;132(6):1346‐61. doi:10.1097/ALN.0000000000003303
  • Iyengar K, Bahl S, Vaishya R, Vaish A. Challenges and solutions in meeting up the urgent requirement of ventilators for COVID-19 patients. Diabetes Metab Syndr. 2020;14(4):499–501. doi:10.1016/j.dsx.2020.04.048.
  • Mora Carpio AL, Mora JI Ventilator Management. [Updated 2020 Mar 28.]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available at https://www.ncbi.nlm.nih.gov/books/NBK448186. [Accessed May 15, 2020.]
  • Langer T, Santini A, Bottino N, et al. “Awake” extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering. Crit Care. 2016;20(1):150. doi:10.1186/s13054-016-1329-y
  • Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, co-morbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA. 2020;323(20):2052–2059. doi:10.1001/jama.2020.6775
  • Mert E, Arzu T, Balam YB, Murat A. Infections in the elderly critically ill patients. Frontiers Medicine. 2019;6:118. doi:10.3389/fmed.2019.00118
  • World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim Guidance; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf. (Accessed June 21, 2020.)
  • Zaim S, Chong JH, Sankaranarayanan V, Harky A. COVID-19, and multi-organ response. Curr Probl Cardiol. 2020;45:100618. doi:10.1016/j.cpcardiol.2020.100618
  • Cao X. COVID-19: immunopathology and its implications for therapy. Nat Rev Immunol. 2020;20(5):269‐70. doi:10.1038/s41577-020-0308-3
  • Corona Tracker Community Research Group. Corona tracker: worldwide COVID-19 outbreak data analysis and prediction. WHO; 2020. Available from: https://www.who.int/bulletin/online_first/20-255695.pdf. (Accessed May 15, 2020.)
  • Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054‐62. doi:10.1016/S0140-6736(20)30566-3
  • Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708‐20. doi:10.1056/NEJMoa2002032
  • Ranieri VM, Rubenfeld GD, et al.; ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526–2533. doi:10.1001/jama.2012.5669.
  • Sommerstein R. Preventing a COVID-19 pandemic. BMJ. 2020;368:m810.
  • Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020;8:e21. doi:10.1016/S2213-2600(20)30116-8
  • Yang J, Zheng Y, Gou X, et al. Prevalence of co-morbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis. Int J Infect Dis. 2020;94:91–95. doi:10.1016/j.ijid.2020.03.01
  • Grasselli G, Zangrillo A, Zanella A, et al. Baseline characteristics and outcome of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020;323(16):1674–1681. doi:10.1001/jama.2020.5394
  • Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 – COVID-NET, 14 States, March 1–30. MMWR Morb Mortal Wkly Rep. 2020;69(15):458–464. doi:10.15585/mmwr.mm6915e3
  • Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor recognition by the novel coronavirus from wuhan: an analysis based on decade-long structural studies of SARS Coronavirus. J Virol. 2020;94(7):e00127–20. doi:10.1128/JVI.00127-20
  • Cell Editorial Team. Embracing the Landscape of Therapeutics. Cell. 2020 Apr 2;181(1):1-3. doi:10.1016/j.cell.2020.03.025
  • De Abajo FJ, Rodríguez-Martín S, Lerma V, et al. Use of renin-angiotensin-aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study. Lancet. 2020;395(10238):1705‐14. doi:10.1016/S0140-6736(20)31030-8
  • Schiffrin EL, Flack JM, Ito S, Muntner P, Webb RC. Hypertension and COVID-19. Am J Hypertens. 2020;33(5):373‐4. doi:10.1093/ajh/hpaa057
  • Shah BR, Hux JE. Quantifying the risk of infectious diseases for people with diabetes. Diabetes Care. 2003;26(2):510–513. doi:10.2337/diacare.26.2.510
  • Muller LM, Gorter KJ, Hak E, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41(3):281–288. doi:10.1086/431587
  • Yang JK, Feng Y, Yuan MY. Plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with SARS. Diabet Med. 2006;23(6):623–628. doi:10.1111/j.1464-5491.2006.01861.x
  • Alqahtani FY, Aleanizy FS, Ali El Hadi Mohamed R, et al. Prevalence of co-morbidities in cases of Middle East respiratory syndrome coronavirus: a retrospective study. Epidemiol Infect. 2018;147::1–5. doi:10.1017/S0950268818002923
  • Cariou B, Hadjadj S, Wargny M, et al. Phenotypic characteristics and prognosis of inpatients with COVID-19 and diabetes: the CORONADO study. Diabetologia. 2020:1‐16. doi:10.1007/s00125-020-05180-x.
  • Jung YJ, Yoon JL, Kim HS, Lee AY, Kim MY, Cho JJ. Atypical clinical presentation of geriatric syndrome in elderly patients with pneumonia or coronary artery disease. Ann of Geri Med and Res. 2017;21(4):158–163. doi:10.4235/agmr.2017.21.4.158
  • D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus disease 2019 in geriatrics and long-term care: the ABCDs of COVID-19. J Am Geriatr Soc. 2020;68(5):912–917. doi:10.1111/jgs.16445
  • Holroyd-Leduc J, Gandell D, Alana Miller A, Dmitriy Petrov D. COVID-19 in Older Adults. University of Toronto; 2020. Available from https://www.rgptoronto.ca/wp-content/uploads/2020/04/COVID-19-Presentations-in-Frail-Older-Adults-U-of-C-and-U-fo-T.pdf. (Accessed July 19, 2020.)
  • Malone ML, Hogan TM, Perry A, et al. COVID-19 in older adults: key points for emergency department providers. J Geri Emerg Med. 2020;1(4):1–11.
  • Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182. doi:10.1136/bmj.m1182
  • World Health Organization. Strengthening the health system response to covid-19 preventing and managing the Covid-19 pandemic across long-term care services in the WHO. European Region; 2020. Available from https://apps.who.int/iris/bitstream/handle/10665/333067/WHO-EURO-2020-804-40539-54460-eng.pdf?sequence=1&isAllowed=y. (Accessed July 19, 2020.)
  • Mair A, Fernandez-Llimos F, Alonso A, et al. The sympathy consortium. Polypharmacy management by 2030: a patient safety challenge. Coimbra: SYMPATHY Consortium. 2017.
  • Mlodinow SG, Linn BS, Mahvan T, Ramer LN, Ngaima NM. Strategies to reduce and prevent polypharmacy in older patients. J Fam Pract. 2019;68(8):429‐40.
  • Dwyer LL, Han B, Woodwell DA, Rechtsteiner EA. Polypharmacy in nursing home residents in the United States: results of the 2004 national nursing home survey. Am J Geriatr Pharmacother. 2010;8(1):63‐72. doi:10.1016/j.amjopharm.2010.01.001
  • Cooper JA, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open. 2015;5(12):e009235. doi:10.1136/bmjopen-2015-009235
  • World Health Organization. Regional strategy for patient-safety in the WHO South-East Asia Region; (2016–2025). Available from: https://apps.who.int/iris/bitstream/handle/10665/205839/B5215.pdf?sequence=1. (Accessed June 21, 2020.)
  • World Health Organization. Medication safety in polypharmacy. Available from: https://apps.who.int/iris/bitstream/handle/10665/325454/WHO-UHC-SDS-2019.11-eng.pdf?sequence=1&isAllowed=y. (Accessed June 21, 2020.)
  • World Health Organization (WHO). Medication Without Harm - Global Patient Safety Challenge on Medication Safety. Geneva: World Health Organization; 2017.
  • Yang J, Liao Y, Lin W-B, et al. Prescribing errors in electronic prescriptions for outpatients intercepted by pharmacists and the impact of prescribing workload on error rate in a Chinese tertiary-care women and children’s hospital. BMC Health Serv Res. 2019;19:1013. doi:10.1186/s12913-019-4843-1
  • Avery A, Barber N, Ghaleb M, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. London: General Medical Council. 2012;227p.
  • Sears K, Scobie A, Mackinnon NJ. Patient-related risk factors for self-reported medication errors in hospital and community settings in 8 countries. Can Pharm J. 2012;145(2):88–93. doi:10.3821/145.2.cpj88
  • Sabzwari SR, Qidwai W, Bhanji S. Polypharmacy in elderly: a cautious trail to tread. J Pak Med Assoc. 2013;63(5):624‐27.
  • Arnoldo L, Cattani G, Cojutti P, Pea F, Brusaferro S. Monitoring polypharmacy in healthcare systems through a multi-setting survey: should we put more attention on long term care facilities? J Public Health Res. 2016;5(3):745. doi:10.4081/jphr.2016.745
  • Duncan P, Duerden M, Payne RA. Deprescribing: a primary care perspective. Eur J Hosp Pharm. 2017;24(1):37–42. doi:10.1136/ejhpharm-2016-000967
  • Ross SB, Wilson MG, Papillon‐Ferland L, et al. COVID-SAFER deprescribing guidance for hydroxychloroquine drug interactions in older adults. J Am Geriatr Soc. 2020;68:1636–1646. doi:10.1111/jgs.1662.;.
  • Prybys KM, Melville KA, Hanna JR Polypharmacy in the elderly: clinical challenges in emergency practice. Part i: overview, etiology, and drug interactions. Available from: https://www.reliasmedia.com/articles/119992-polypharmacy-in-the-elderly-clinical-challenges-in-emergency-practice-part-i. (Accessed June 21, 2020).
  • McDonald VM, Simpson JL, Higgins I, Gibson PG. Multidimensional assessment of older people with asthma and COPD: clinical management and health status. Age Ageing. 2011;40(1):42‐9. doi:10.1093/ageing/afq134
  • World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf. (Accessed June 21, 2020.)
  • Smith PF, Dodds M, Bentley D, Yeo K. Dosing will be a key success factor in repurposing antivirals for COVID-19. Br J Clin Pharmacol. 2020. doi:10.1111/bcp.14314
  • Reeve E, Moriarty F, Nahas R, Turner JP, O’Donnell LK, Hilmer SN. A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2018;17(1):39–49. doi:10.1080/14740338.2018.1397625
  • Vande Griend JP Common Polypharmacy Pitfalls. Pharmacy Times; 2009. Available from: https://www.pharmacytimes.com/publications/issue/2009/2009-01/2009-01-9968. (Accessed May 16, 2020).
  • Sarwar MR, Iftikhar S, Sarfraz M. Influence of education level of older patients on polypharmacy, potentially inappropriate medications listed in beer’s criteria, and unplanned hospitalization: a cross-sectional study in Lahore, Pakistan. Medicina. 2018;54(4):57. doi:10.3390/medicina54040057
  • Woodward M. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33:323–328. doi:10.1002/jppr2003334323
  • Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254–1268. doi:10.1111/bcp.12732
  • Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–2012. doi:10.1056/NEJMsa1103053
  • Bennett A, Gnjidic D, Gillett M, et al. Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging. 2014;31(3):225–232. doi:10.1007/s40266-013-0151-3
  • Zechmann S, Trueb C, Valeri F, Streit S, Senn O, Neuner-Jehle S. Barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from Switzerland. BMC Fam Pract. 2019;20(1):64. doi:10.1186/s12875-019-0953-4
  • Lavan AH, Gallagher P. Predicting risk of adverse drug reactions in older adults. Ther Adv Drug Saf. 2016;7(1):11–22. doi:10.1177/2042098615615472
  • Stevenson JM, Williams JL, Burnham TG, et al. Predicting adverse drug reactions in older adults; a systematic review of the risk prediction models. Clin Interv Aging. 2014;9:1581–1593. doi:10.2147/CIA.S65475
  • Thompson W, Lundby C, Graabaek T, et al. Tools for deprescribing in frail older persons and those with limited life expectancy: a systematic review. J Am Geriatr Soc. 2019;67(1):172–180. doi:10.1111/jgs.15616
  • American geriatrics society 2012 beers criteria update expert panel. American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–631. doi:10.1111/j.1532-5415.2012.03923.x
  • Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (screening tool of older person’s prescriptions) and start (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83. doi:10.5414/cpp46072
  • Naugler CT, Brymer C, Stolee P, Arcese ZA. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol. 2000;7(2):103–107.
  • McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ. 1997;156(3):385–391.
  • Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045–1051. doi:10.1016/0895-4356(92)90144-c
  • Wehling M. Multimorbidity and polypharmacy: how to reduce the harmful drug load and yet add needed drugs in the elderly? Proposal of a new drug classification: fit for the aged. J Am Geriatr Soc. 2009;57(3):560–561. doi:10.1111/j.1532-5415.2009.02131.x
  • Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int. 2010;107(3132):543–551. doi:10.3238/arztebl.2010.0543
  • Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165. doi:10.1002/14651858.CD008165.pub3
  • Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med. 2007;167(8):781–787. doi:10.1001/archinte.167.8.781
  • Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508–513. doi:10.1001/archinternmed.2007.106
  • Lowry E, Woodman RJ, Soiza RL, Mangoni AA. Associations between the anticholinergic risk scale score and physical function: potential implications for adverse outcomes in older hospitalized patients. J Am Med Dir Assoc. 2011;12(8):565–572. doi:10.1016/j.jamda.2011.03.006
  • Lowry E, Woodman RJ, Soiza RL, Hilmer SN, Mangoni AA. Drug burden index, physical function, and adverse outcomes in older hospitalized patients. J Clin Pharmacol. 2012;52(10):1584–1591. doi:10.1177/0091270011421489
  • Scott I, Anderson K, Freeman C. Review of structured guides for deprescribing. Eur J Hosp Pharm. 2017;24(1):51–57. doi:10.1136/ejhpharm-2015-000864
  • Onder G, Petrovic M, Tangiisuran B, et al. Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older: the GerontoNet ADR risk score. Arch Intern Med. 2010;170(13):1142–1148. doi:10.1001/archinternmed.2010.153
  • Saedder EA, Lisby M, Nielsen LP, et al. Detection of patients at high risk of medication errors: development and validation of an algorithm. Basic Clin Pharmacol Toxicol. 2016;118(2):143–149. doi:10.1111/bcpt.12473
  • Urbina O, Ferrández O, Grau S, et al. Design of a score to identify hospitalized patients at risk of drug-related problems. Pharmacoepidemiol Drug Saf. 2014;23(9):923–932. doi:10.1002/pds.3634
  • Sakuma M, Bates DW, Morimoto T. Clinical prediction rule to identify high-risk inpatients for adverse drug events: the JADE Study. Pharmacoepidemiol Drug Saf. 2012;21(11):1221–1226. doi:10.1002/pds.3331
  • Cook CE. Potential pitfalls of clinical prediction rules. J Man Manip Ther. 2008;16(2):69–71. doi:10.1179/106698108790818477
  • Iyer S, Goss E, Browder C, Paccione G, Arnsten J. Development and evaluation of a clinical reasoning curriculum as part of an internal medicine residency program. Diagnosis. 2019;6(2):115–119. doi:10.1515/dx-2018-0093
  • McGinn T, Jervis R, Wisnivesky J, Keitz S, Wyer PC. Evidence-based Medicine Teaching Tips Working Group. Tips for teachers of evidence-based medicine: clinical prediction rules (CPRs) and estimating pretest probability. J Gen Intern Med. 2008;23(8):1261–1268. doi:10.1007/s11606-008-0623-z
  • Lindsay J, Dooley M, Martin J, et al. The development and evaluation of an oncological palliative care deprescribing guideline: the ‘OncPal deprescribing guideline’. Support Care Cancer. 2015;23(1):71–78. doi:10.1007/s00520-014-2322-0
  • Reeve E, Gnjidic D, Hilmer S. The role of the OncPal deprescribing guideline in end-of-life care. Support Care Cancer. 2015;23(4):899. doi:10.1007/s00520-014-2445-3
  • Bjerre LM, Farrell B, Hogel M, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: evidence-based clinical practice guideline. Can Fam Physician. 2018;64(1):17–27.
  • Thillainadesan J, Gnjidic D, Green S, Hilmer SN. Impact of deprescribing interventions in older hospitalised patients on prescribing and clinical outcomes: a systematic review of randomised trials. Drugs Aging. 2018;35(4):303–319. doi:10.1007/s40266-018-0536-4
  • Payne RA, Avery AJ. Polypharmacy: one of the greatest prescribing challenges in general practice. Br J Gen Pract. 2011;61(583):83–84. doi:10.3399/bjgp11X556146
  • Khezrian M, McNeil CJ, Murray AD, Myint PK. An overview of prevalence, determinants and health outcomes of polypharmacy. Ther Adv Drug Saf. 2020;11:2042098620933741. doi:10.1177/2042098620933741
  • World Health Organization. Medication safety in polypharmacy. Technical Report; 2019. (WHO/UHC/SDS/2019.11). License: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/rest/bitstreams/1235792/retrieve. (Accessed May 16, 2020.)
  • Cadogan CA, Ryan C, Hughes CM. Appropriate polypharmacy and medicine safety: when many is not too many. Drug Safety. 2016;39(2):109–116. doi:10.1007/s40264-015-0378-5
  • Rochon PA Drug prescribing for older adults. Available from: https://www.uptodate.com/contents/drug-prescribing-for-older-adults. (Accessed June 21, 2020.)
  • Wilfling D, Hinz A, Steinhäuser J. Big data analysis techniques to address polypharmacy in patients - a scoping review. BMC Fam Pract. 2020;21(1):180. doi:10.1186/s12875-020-01247-1
  • Ailabouni NJ, Hilmer SN, Kalisch L, Braund R, Reeve E. COVID-19 pandemic: considerations for safe medication use in older adults with multimorbidity and polypharmacy. J Gerontol. doi:10.1093/gerona/glaa104
  • SYMPATHY project: innovation for appropriate polypharmacy in the elderly. In: Digital Single Market [Website]. Brussels: European Commission. 2016. Available at: (https://ec.europa.eu/digital-singlemarket/en/news/simpathy-project-innovationappropriate-polypharmacy-elderly.) (accessed 21 June 2020.)
  • Wilson M, Mair A, Dreischulte T, Witham M. Prescribing to fit the needs of older people: the NHS Scotland Polypharmacy Guidance, 2nd edition. J R Coll Physicians Edinb. 2015;45(2):108–113. doi:10.4997/JRCPE.2015.204
  • World Health Organization. Advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019‐nCoV) outbreak: Interim Guidance; 2020. Available from: https://www.who.int/docs/default-source/documents/advice-on-the-use-of-masks-2019-ncov.pdf. (Accessed June 21, 2020.)
  • Centers for Disease Control and Prevention. 2019‐nCoV: prevention & Treatment; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html. (Accessed June 21, 2020.)
  • Haque M, Islam T, Rahman NAA, McKimm J, Abdullah A, Dhingra S. Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries. Risk Manag Healthc Policy. 2020;13:409-426. doi:10.2147/RMHP.S239074
  • Lim WH, Wong WM. COVID-19: notes from the front line, singapore’s primary health care perspective. Ann Fam Med. 2020;18(3):259–261. doi:10.1370/afm.2539
  • Lee VJ, Chiew CJ, Khong WX. Interrupting transmission of COVID-19: lessons from containment efforts in Singapore. J Travel Med. 2020;27(3):taaa039. doi:10.1093/jtm/taaa039
  • Paudel S, Dangal G, Chalise A, Bhandari TR, Dangal O. The coronavirus pandemic: what does the evidence show? J Nepal Health Res Counc. 2020;18(1):1–9. doi:10.33314/jnhrc.v18i1.2596
  • Qian X, Ren R, Wang Y, et al. Fighting against the common enemy of COVID-19: a practice of building a community with a shared future for mankind. Infect Dis Poverty. 2020;9(1):34. doi:10.1186/s40249-020-00650-1
  • Chang BB, Chiu TY. Ready for a long fight against the COVID-19 outbreak: an innovative model of tiered primary health care in Taiwan. BJGP Open. 2020;4(2):bjgpopen20X101068. doi:10.3399/bjgpopen20X101068
  • Lin C, Braund WE, Auerbach J, et al. Policy decisions and use of information technology to fight COVID-19, Taiwan. Emerg Infect Dis. 2020;26(7):1506–1512. doi:10.3201/eid2607.200574
  • Kumar P. How to strengthen primary health care. J Family Med Prim Care. 2016;5(3):543–546. doi:10.4103/2249-4863.197263
  • Watkins DA, Jamison DT, Mills T, et al. Universal health coverage and essential packages of care. In: Disease Control Priorities: Improving Health and Reducing Poverty. Jamison DT, Gelband H, Horton S, et al., eds. 3rd ed. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2017.
  • Haque M. Combating covid-19: a coordinated efforts of healthcare providers and policy makers with global participation are needed to achieve the desired goals. Bang J Med Sci. 2020;19(Special Issue on Covid19):01–05.
  • Haque M. The COVID-19 pandemic - a global public health crisis: a brief overview regarding pharmacological interventions. Pesquisa Brasileira Em Odontopediatria e Clínica Integrada. 2020;20(\(Supp1)):e0146. doi:10.1590/pboci.2020.137
  • Thomas SL, Wakerman J, Humphreys JS. What core primary health care services should be available to Australians living in rural and remote communities? BMC Fam Pract. 2014;15:143. doi:10.1186/1471-2296-15-143
  • Lyle D, Saurman E, Kirby S, Jones D, Humphreys J, Wakerman J. What do evaluations tell us about implementing new models in rural and remote primary health care? Findings from a narrative analysis of seven service evaluations conducted by an Australian Centre of Research Excellence. Rural Remote Health. 2017;17(3):3926. doi:10.22605/RRH329