Effects of a pilot multidisciplinary clinic for frequent attending elderly patients on deprescribing (original) (raw)

Alison Mudge A B , Katherine Radnedge C D , Karen Kasper A , Robert Mullins A , Julie Adsett A , Serena Rofail A C D , Sophie Lloyd A and Michael Barras C D E

+ Author Affiliations

- Author Affiliations

A Department of Internal Medicine, Level 3, Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, Brisbane, Qld 4029, Australia. Email: Alison.mudge@health.qld.gov.au; karen.kasper@health.qld.gov.au; robert.mullins@qut.edu.au; julie.adsett@health.qld.gov.au; serena.rofail@health.qld.gov.au; sophie.lloyd@health.qld.gov.au

B School of Medicine, The University of Queensland, St Lucia, Brisbane, Qld 4072, Australia.

C Pharmacy Department, Level 1, Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, Brisbane, Qld 4029, Australia. Email: katherine.radnedge@gmail.com

D School of Pharmacy, The University of Queensland, St Lucia, Brisbane, Qld 4072, Australia.

E Corresponding author. Email: michael.barras@health.qld.gov.au

Australian Health Review 40(1) 86-91 https://doi.org/10.1071/AH14219
Submitted: 24 November 2014 Accepted: 28 April 2015 Published: 6 July 2015

Abstract

Objective Multimorbidity and associated polypharmacy are risk factors for hospital re-admission. The Targeting Hospitalization Risks in Vulnerable Elders (THRIVE) clinic is a novel multidisciplinary out-patient clinic to improve transitions of care and decrease re-admission risk for older medical patients with frequent hospital admissions. This pilot study examined the effect of the THRIVE model on medication count, tablet load and potentially inappropriate medicines (PIMs).

Methods Participants with frequent medical admissions were referred within 2 weeks of discharge from hospital and assessed at baseline and then at 4 and 12 weeks by the THRIVE team. A thorough reconciliation of all medications was performed collaboratively by a clinical pharmacist and a physician. Optimising medications, including deprescribing, was in collaboration with the participants’ general practitioner. The complete medication history of each patient was compared retrospectively by an independent assessor at baseline and after the 12-week clinic, comparing total number of regular medications, tablet load and PIMs (measured using the Screening Tool of Older Persons Prescriptions (STOPP) tool).

Results All 17 participants attending the pilot THRIVE clinic were included in the study. At 12 weeks, there was a significant reduction in mean medication count (from 14.3 to 11.2 medications; P < 0.001) and mean tablet load (from 20.5 to 16.9 tablets; P < 0.01). There was an absolute reduction in the total number of PIMs from 38 to 14. Common medications deprescribed included opioids, tricyclic antidepressants, benzodiazepines and diuretics.

Conclusions Patients who attended the THRIVE clinic had a significant reduction in medication count and tablet load. The pilot study demonstrates the potential benefits of a multidisciplinary out-patient clinic to improve prescribing and reduce unwarranted medications in an elderly population. An adequately powered comparative study would allow assessment of clinical outcomes and costs.

What is known about the topic? Elderly patients are prone to polypharmacy. The identification and deprescribing of potentially inappropriate medications is effective in reducing adverse drug events in this population. However, acute hospitalisation is not always the ideal setting to initiate deprescribing.

What does the paper add? Intensive multidisciplinary out-patient care for frequently re-admitted patients optimises their medication management plan and helps reduce the use of unwarranted medications.

What are the implications for practitioners? Effective deprescribing in elderly patients can be achieved after hospital discharge using a multidisciplinary collaborative model, but costs and clinical benefits require further investigation.

References

[1] Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother 2007; 5 263–303.
| Pharmacodynamics in older adults: a review.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2sXhtlCqtr7K&md5=25af248406c22bf76766f420d52ff2ceCAS | 17996666PubMed |

[2] Franchi C, Nobili A, Mari D, Tettamanti M, Djade CD, Pasina L, Salerno F, Corrao S, Marengoni A, Iorio A, Marcucci M, Mannucci PM, Investigators R. Risk factors for hospital readmission of elderly patients. Eur J Intern Med 2013; 24 45–51.
| Risk factors for hospital readmission of elderly patients.Crossref | GoogleScholarGoogle Scholar | 23142413PubMed |

[3] Willson MN, Greer CL, Weeks DL. Medication regimen complexity and hospital readmission for an adverse drug event. Ann Pharmacother 2014; 48 26–32.
| Medication regimen complexity and hospital readmission for an adverse drug event.Crossref | GoogleScholarGoogle Scholar | 24259639PubMed |

[4] Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011; 365 2002–12.
| Emergency hospitalizations for adverse drug events in older Americans.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXhs1SntLrO&md5=31e0b15a48282199632e39176da799bbCAS | 22111719PubMed |

[5] Mangin D, Health I, Jamoulle M. Beyond diagnosis: rising to the multimorbidty challenge. BMJ 2012; 344 e3526
| Beyond diagnosis: rising to the multimorbidty challenge.Crossref | GoogleScholarGoogle Scholar | 22695898PubMed |

[6] Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2012; 5 CD008165
| 22592727PubMed |

[7] 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; 69 543–52.
| Potentially inappropriate prescribing and cost outcomes for older people: a national population study.Crossref | GoogleScholarGoogle Scholar | 20573091PubMed |

[8] Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 2011; 171 1013–19.
| Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients.Crossref | GoogleScholarGoogle Scholar | 21670370PubMed |

[9] O’Mahony D, Gallagher P. Inappropriate prescribing in the older population: need for new criteria. Age Ageing 2008; 37 138–41.
| Inappropriate prescribing in the older population: need for new criteria.Crossref | GoogleScholarGoogle Scholar | 18349010PubMed |

[10] 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; 28 237–53.
| Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes.Crossref | GoogleScholarGoogle Scholar | 22500541PubMed |

[11] Kaur S, Mitchell G, Vitetta L, Roberts M. Interventions that can reduce inappropraite prescribing in the elderly. A systematic review. Drugs Aging 2009; 26 1013–28.
| Interventions that can reduce inappropraite prescribing in the elderly. A systematic review.Crossref | GoogleScholarGoogle Scholar | 19929029PubMed |

[12] Thompson W, Farrell B. Deprescribing: what is it and what does the evidence tell us? Can J Hosp Pharm 2013; 66 201–2.
| Deprescribing: what is it and what does the evidence tell us?Crossref | GoogleScholarGoogle Scholar | 23814291PubMed |

[13] Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56 1946–52.
| Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process.Crossref | GoogleScholarGoogle Scholar | 18771457PubMed |

[14] Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med 2010; 170 1648–54.
| Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.Crossref | GoogleScholarGoogle Scholar | 20937924PubMed |

[15] Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol 2014; 78 738–47.
| Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process.Crossref | GoogleScholarGoogle Scholar | 24661192PubMed |

[16] Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, Tulkens PM. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc 2007; 55 658–65.
| Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial.Crossref | GoogleScholarGoogle Scholar | 17493184PubMed |

[17] Page R, Linnebur S, Bryant L, Ruscin J. Inappropriate prescribing in the hospitalised elderly patient: defining the problem, evaluation tools and possible solutions. Clin Interv Aging 2010; 5 75–87.
| Inappropriate prescribing in the hospitalised elderly patient: defining the problem, evaluation tools and possible solutions.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3cXkvVKjsbk%3D&md5=1d8971482804b339092afe37d9a0c46fCAS | 20396637PubMed |

[18] Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol 2013; 69 319–26.
| Medication prescribing in frail older people.Crossref | GoogleScholarGoogle Scholar | 22965651PubMed |

[19] O’Connor MN, Gallagher P, Byrne S, O’Mahony D. Adverse drug reactions in older patients during hospitalisation: are they predictable? Age Ageing 2012; 41 771–6.
| Adverse drug reactions in older patients during hospitalisation: are they predictable?Crossref | GoogleScholarGoogle Scholar | 22456465PubMed |

[20] Mudge AM, Kasper K, Clair A, Redfern H, Bell JJ, Barras MA, Dip G, Pachana NA. Recurrent readmissions in medical patients: a prospective study. J Hosp Med 2011; 6 61–7.
| Recurrent readmissions in medical patients: a prospective study.Crossref | GoogleScholarGoogle Scholar | 20945294PubMed |

[21] Kripalani S, Jackson A, Schnipper J, Coleman E. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2007; 2 314–23.
| Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.Crossref | GoogleScholarGoogle Scholar | 17935242PubMed |

[22] Mudge A, Shakhovskoy R, Karrasch A. Quality of transitions in older medical patients with frequent readmissions: opportunities for improvement. Eur J Intern Med 2013; 24 779–83.
| Quality of transitions in older medical patients with frequent readmissions: opportunities for improvement.Crossref | GoogleScholarGoogle Scholar | 24055382PubMed |

[23] Mudge AM, Barras MA, Adsett J, Mullins R, Kasper K, Lloyd S. Improving care transitions in frequently admitted medical patients. J Am Geriatr Soc 2014; 62 1994–6.
| Improving care transitions in frequently admitted medical patients.Crossref | GoogleScholarGoogle Scholar | 25333542PubMed |

[24] Gallagher P, O’Mahoney D. STOPP (Screening Tool of Older Persons’ Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing 2008; 37 673–9.
| STOPP (Screening Tool of Older Persons’ Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria.Crossref | GoogleScholarGoogle Scholar | 18829684PubMed |

[25] Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011; 89 845–54.
| Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3MrjtF2msg%3D%3D&md5=80f3e9799d0b14a987aa0762a47d71d5CAS | 21508941PubMed |

[26] van der Cammen R, Rajkumar C, Onder G, Sterke C, Petrovic M. Drug cessation in complex older adults: time for action. Age Ageing 2014; 43 20–5.
| Drug cessation in complex older adults: time for action.Crossref | GoogleScholarGoogle Scholar |

[27] Nyborg G, Straand J, Brekke M. Inappropriate prescribing for the elderly: a modern epidemic? Eur J Clin Pharmacol 2012; 68 1085–94.
| Inappropriate prescribing for the elderly: a modern epidemic?Crossref | GoogleScholarGoogle Scholar | 22349159PubMed |

[28] Borne R, Cumbler E, Glasheen J. Reducing polypharmacy: is hospitalization the right time? Arch Intern Med 2011; 171 869–70.
| Reducing polypharmacy: is hospitalization the right time?Crossref | GoogleScholarGoogle Scholar | 21555674PubMed |

[29] American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60 616–31.
| American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults.Crossref | GoogleScholarGoogle Scholar | 22376048PubMed |