Impact of deprescribing rounds on discharge prescriptions: an interventional trial (original) (raw)

Abstract

Background Successful deprescribing practices are required to address issues associated with polypharmacy but are hindered by minimal interprofessional collaboration, time constraints, concern for negative outcomes, and absence of a systematic and evidence-based approach. Objective Determine the impact of pharmacist-led deprescribing rounds within a clinical teaching unit (CTU) the number of home medications discontinued upon hospital discharge. Setting Canadian tertiary care hospital. Methods Prospective, dual-arm, interventional study conducted in a single centre, from November 23rd, 2015 to August 30th, 2016. All patients ≥ 19 years old admitted under the CTU were considered for enrolment if on medication(s) prior to admission and patients were excluded if not taking any medications. Study arm allocation alternated daily between the two teams. The control arm operated as per standard whereas the intervention arm’s pharmacist used a deprescribing guide and medication review to identify medications eligible for discontinuation prior to discussing during daily rounds. Discharge documents communicated medication changes to patient and primary healthcare providers. The study was sufficiently powered. Main outcome measure The difference of number of home medications discontinued at discharge between the intervention and control groups. Results 171 and 187 patients were allocated to the intervention and control arms, respectively. No significant differences of baseline characteristics existed between groups. Main outcome measure results showed that deprescribing rounds resulted in significantly more medications deprescribed compared to control (65% vs. 38%; p = 0.001). The rates of readmission and emergency department visits were reduced in the intervention arm. Conclusions Incorporating deprescribing rounds into routine care led to significantly greater discontinuation of medications without increasing rate of emergency department visits or hospital admissions.

Trial registration ISRCTN11751440

Access this article

Log in via an institution

Subscribe and save

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. (CIHI) CI for HI. Drivers of Prescription Drug Spending in Canada—drug_spend_drivers_en.pdf (Internet) (cited 2017 Mar 12). https://www.cihi.ca/en/drug_spend_drivers_en.pdf.
  2. Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870–4.
    Article CAS PubMed Google Scholar
  3. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process: patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738–47.
    Article PubMed PubMed Central Google Scholar
  4. O’Sullivan D, O’Mahony D, O’Connor MN, Gallagher P, Cullinan S, O’Sullivan R, et al. The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients. Drugs Aging. 2014;31(6):471–81.
    Article PubMed Google Scholar
  5. Frank C. Deprescribing: a new word to guide medication review. CMAJ. 2014;186(6):407–8.
    Article PubMed PubMed Central Google Scholar
  6. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827.
    Article PubMed Google Scholar
  7. Thompson W, Farrell B. Deprescribing: what is it and what does the evidence tell us? Can J Hosp Pharm. 2013;66(3):201–2.
    PubMed PubMed Central Google Scholar
  8. Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What are priorities for deprescribing in elderly patients? capturing the voice of practitioners: a modified Delphi process. PLoS. 2015;10:1–16.
    Google Scholar
  9. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? a systematic review of definitions. BMC Geriatr (Internet). 2017 Oct 10 (cited 2018 May 27);17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635569/.
  10. Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis: effect of deprescribing in older adults on mortality and health. Br J Clin Pharmacol. 2016;82(3):583–623.
    Article PubMed PubMed Central Google Scholar
  11. Vogel L. Network tackles overprescribing. CMAJ. 2016;188(15):1075.
    Article PubMed PubMed Central Google Scholar
  12. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. The benefits and harms of deprescribing. Med J Aust. 2014;201(7):386–9.
    Article PubMed Google Scholar
  13. Schuling J, Gebben H, Veehof LJG, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract (Internet). 2012 Dec (cited 2016 Dec 18);13(1). http://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-13-56.
  14. Gnjidic D, Couteur DGL, Hilmer SN. Discontinuing drug treatments. BMJ. 2014;21(349):7013.
    Article Google Scholar
  15. Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med. 2012;28(2):237–53.
    Article PubMed Google Scholar
  16. Howland RH. Deprescribing to reduce medication use: will this help your patient? J Psychosoc Nurs Ment Health Serv. 2016;54(11):21–4.
    Article PubMed Google Scholar
  17. Reeve E, Wiese MD. Benefits of deprescribing on patients’ adherence to medications. Int J Clin Pharm. 2014;36(1):26–9.
    Article PubMed Google Scholar
  18. Hanlon JT, Weinberger M, Samsa GP, Schmader KE, Uttech KM, Lewis IK, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100(4):428–37.
    Article CAS PubMed Google Scholar
  19. Anderson K, Freeman C, Rowett D, Burrows J, Scott I, Rigby D. Polypharmacy, deprescribing and shared decision-making in primary care: the role of the accredited pharmacist: the role of the accredited pharmacist. J Pharm Pract Res. 2015;45(4):446–9.
    Article Google Scholar
  20. Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017;1(38):3–11.
    Article Google Scholar
  21. Harriman K, Howard L, McCracken L. Deprescribing medication for frail elderly patients in nursing homes: a survey of Vancouver family physicians. BCMJ. 2014;56(9):436–41.
    Google Scholar
  22. Kaur S, Mitchell G, Vitetta L, Roberts MS. Interventions that can reduce inappropriate prescribing in the elderly: a systematic review. Drugs Aging. 2009;26(12):1013–28.
    Article PubMed Google Scholar
  23. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430–4.
    PubMed Google Scholar
  24. Canadian Deprescribing Network (CaDeN) (Internet). Deprescribing.org. (cited 2016 Dec 19). http://deprescribing.org/caden/.
  25. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33(4):323–8.
    Article Google Scholar
  26. Johansson T, Abuzahra ME, Keller S, Mann E, Faller B, Sommerauer C, et al. Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis: impact of strategies to reduce polypharmacy. Br J Clin Pharmacol. 2016;82(2):532–48.
    Article PubMed PubMed Central Google Scholar
  27. Alldred DP, Kennedy M-C, Hughes C, Chen TF, Miller P. Interventions to optimise prescribing for older people in care homes. In: The Cochrane Collaboration, editor. Cochrane database of systematic reviews (Internet). Chichester: Wiley; 2016 (cited 2016 Dec 19). http://doi.wiley.com/10.1002/14651858.CD009095.pub3.
  28. Linsky A, Simon SR, Stolzmann K, Meterko M. Patient perceptions of deprescribing (PPoD): survey development and psychometric assessment. Med Care. 2016;55:306–13.
    Article Google Scholar
  29. Farrell B, Pottie K, Rojas-Fernandez CH, Bjerre LM, Thompson W, Welch V. Methodology for developing deprescribing guidelines: using evidence and GRADE to guide recommendations for deprescribing. Quinn TJ, editor. PLoS ONE. 2016;11(8):e0161248.
    Article CAS PubMed PubMed Central Google Scholar
  30. McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised older patients receiving multiple medications: deprescribing in older patients. Intern Med J. 2016;46(1):35–42.
    Article CAS PubMed Google Scholar
  31. Martin P, Tamblyn R, Ahmed S, Benedetti A, Tannenbaum C. A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial. Trials (Internet). 2015 Dec (cited 2016 Dec 19);16(1). http://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0791-1.

Download references

Author information

Authors and Affiliations

  1. Department of Pharmacy, Nanaimo Regional General Hospital, 1200 Dufferin Crescent, Nanaimo, BC, V9S 2B7, Canada
    Rachel Edey
  2. Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
    Rachel Edey, Nicholas Edwards & Dan Martinusen
  3. Department of Pharmacy, Royal Jubilee Hospital, 1952 Bay St, Royal Block 242, Victoria, BC, V8R 1J8, Canada
    Nicholas Edwards, Ajay Bains & Dan Martinusen
  4. Internal Medicine, Royal Jubilee Hospital, 1952 Bay St, Victoria, BC, V8R 1J8, Canada
    Jonah Von Sychowski & Jim Spence
  5. Island Medical Program, The University of Victoria, 3800 Finnerty Rd, Victoria, BC, V8P 5C2, Canada
    Jonah Von Sychowski & Jim Spence

Authors

  1. Rachel Edey
    You can also search for this author inPubMed Google Scholar
  2. Nicholas Edwards
    You can also search for this author inPubMed Google Scholar
  3. Jonah Von Sychowski
    You can also search for this author inPubMed Google Scholar
  4. Ajay Bains
    You can also search for this author inPubMed Google Scholar
  5. Jim Spence
    You can also search for this author inPubMed Google Scholar
  6. Dan Martinusen
    You can also search for this author inPubMed Google Scholar

Corresponding author

Correspondence toRachel Edey.

Ethics declarations

Conflicts of interest

Authors Rachel Edey, Nicholas Edwards, Jonah Von Sychowski, Ajay Bains, Jim Spence, and Dan Martinusen do not have any conflicts of interest to disclose or financial interests to declare.

Electronic supplementary material

Rights and permissions

About this article

Cite this article

Edey, R., Edwards, N., Von Sychowski, J. et al. Impact of deprescribing rounds on discharge prescriptions: an interventional trial.Int J Clin Pharm 41, 159–166 (2019). https://doi.org/10.1007/s11096-018-0753-2

Download citation

Keywords