When people ask me why I founded a medication management company, I tell them the story of my friend Bob’s mom. As Bob described his mom, she was a relatively health, ambulatory, 90 year old woman with initial signs of dementia…until she started falling. After the first fall I suggested to Bob that we take a look at her medication list to see if she was taking any falls risk medications, but Bob thought that wasn’t the cause of the fall. The second fall landed Bob’s mom in the ER and earned her a visit in a rehab facility. After the third fall, which was accompanied by a broken wrist, Bob acquiesced and showed up at my office with his mom’s medication administration record – all 4 pages!
I looked up at him and said – “I thought your mom was pretty healthy”. She was using 28 medications (not including PRN medications). When I noted that the first two medications on the list were indicated primarily for seizure disorders, Bob looked confused and said – “My mom doesn’t have a seizure disorder”…and so began our deprescribing journey.
I began by trying to associate a diagnosis to every drug, when I couldn’t do this I questioned the PCP. Some of the medications without diagnoses he agreed to discontinue. However, for those medications that had been prescribed by an active specialist he refused to deprescribe, despite no documentation to support use. So I began to engage the specialists. Interestingly, most of the specialists were very compliant with my interest in deprescribing medication and readily provided an evidence based rationale for the medication’s use or discontinued the therapy.
My only “hold out” was the cardiologist. She had Bob’s mom on a calcium channel blocker and a beta-blocker. I could see no indication of a rate or rhythm problem and only mild hypertension, so I believed this combination to be non-evidenced based and a falls risk. Unfortunately, I was getting no response to my recommendation. Finally, I said to Bob that the only alternative left was to go to Bob’s mom’s next cardiology appointment. To be sure this was the first time the cardiologist had ever encountered a patient’s personal clinical pharmacist, but when the cardiologist figured out what I was trying to accomplish she readily agreed and swapped two agents plagued with adverse events for one with a limited adverse event profile.
In the end, Bob’s mom went from 28 to 5 chronic medications and the only PRN medication she retained was acetaminophen. Not only did we decrease total medication burden, but we decreased anticholinergic load, eliminated all opioid use, decreased medication driven falls risk and decreased the cost of the medication regimen. After 2 weeks, Bob called me to tell me that his mom’s dementia seemed to be much less severe and that she felt less disoriented, an indication (albeit subjective) of an improved quality of life.
Bringing this vignette to thousands of overtreated seniors is what makes me excited about getting out of bed and to work every morning.
The concept of deprescribing is not new or novel. Over the past 10 years, over 50 peer reviewed journal articles have been published articulating the value of deprescribing (click her to access literature review). Almost all of the authors agree that deprescribing is:
- Of planned and supervised tapering or safe withdrawal of potentially legacy or inappropriate medication
- Focused on reducing inappropriate polypharmacy, medication burden and harm, in an effort to improve patient outcomes and decrease cost.
- Performing deprescribing is best when approached in an iterative fashion reducing medicines or doses one at a time
- A “team sport” that requires care team participation and coordination.
Alabouni et. al. (2019) studied the effects of a deprescribing effort focused on anticholinergic and sedative medications in patients in residential care facilities. The main outcome measure of the study was change in the Drug Burden Index (DBI) – assessed at 3 and 6 months after implementing the deprescribing intervention. The response to deprescribing was good with 72% of pharmacists deprescribing recommendations being implemented and 96% of residents agreed to the deprescribing recommendations. The deprescribing effort resulted in a significant reduction in DBI scores, number of falls and adverse drug reactions (evaluated at 6 months). In addition, the effort resulted in residents exhibiting lower depression and frailty scores.
Even in very complex patients deprescribing can be conducted safely and successfully. McIntyre et. al. conducted an evaluation of deprescribing in 240 patients in a tertiary-care outpatient hemodialysis unit. The authors evaluated the decrease in medication burden as defined by number of medications deprescribed. Five (5) medication classes were specifically targeted for deprescribing – quinines, diuretics, α1-blockers, proton pump inhibitors, and statins. The patients were screened and 171 of 240 (71%) patients were prescribed at least 1 of the 5 target medications. Forty 40 of the 171 patients were deemed eligible for deprescribing and 35 of 40 (88%) eligible patients had the medications deprescribed. Thirty-one (31) of 40 (78%) target medications had been completely deprescribed (at 6 months). At the end of the study, 57% of patients were taking fewer medications than at baseline and no adverse events were observed in the patients with deprescribed medication.
Deprescribing in Practice
Various authors have conducted both quantitative and qualitative analysis to understand barriers to deprescribing. While many of these studies were not US based, the barriers identified would appear to be generalizable to the US healthcare system.
- Patient familiarity. In 2017 Turner et. al conducted an evaluation of 2665 community dwelling seniors. Over two-thirds (65.2%) of the seniors were familiar with the concept of medication-induced harms. However, only 6.9% recognized the term deprescribing. Consequently, patient initiated deprescribing conversations were infrequent. However the authors found that patients who were more knowledgeable about medication harm, had a familiarity with the term deprescribing, displayed health information-seeking behavior were more likely to initiate a deprescribing conversation. This indicates that if deprescribing were to be successful it would likely need to begin with a health care provider initiated conversation.
- Physician perspective. Wallis et. al. (2018) explored the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice. The authors conducted semi-structured interviews to identify themes. Physicians described deprescribing as “swimming against the tide” of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management.
Despite the evidence supporting the practice of deprescribing, the implementation of active deprescribing activity is limited by a “perfect storm” of patient unfamiliarity and prescriber reticence.
Deprescribing and MTM
It would seem that an MTM program would be the perfect place to house a deprescribing program as the patients identified as eligible for MTM are generally high utilizing patients. Unfortunately, the typical MTM program structure with its patient (vs. prescriber) focus and single CMR does not lend itself to the systematic, iterative prescriber intervention that is required for deprescribing.
At CSS we have developed our Deprescribing Companion Program. While the Deprescribing Companion Program can be can be operated as a stand alone program in any line of business (Medicare, Medicaid, Commercial), it was especially designed to be run inside a Medicare Part D MTM program and provide a demonstrable clinical and financial ROI. Setting up the Companion Deprescribing Program is simple and easy.
- Determine the number of drugs you want to use to determine polypharmacy. If your not sure CSS can run simulations to see how big of a case load you would produce at different cut points.
- Then use the CSS deprescribing protocol to begin your work. If you don’t have enough clinicians to run a deprescribing program – no worries – CSS can support you with clinicians to power the deprescribing effort.
- Watch the remarkable effects of deprescribing. We will provide monthly reports showing you the decreases in drug counts, regimen costs, anticholinergic – sedative – opioid load.
Happy to discuss how you might incorporate the Deprescribing Companion Program into your medication management efforts.
Best – Jim
Jim Notaro, RPh, PhD
Founder and Chief Clinical Officer