Deprescribing as a Clinical Improvement Focus

Thiruvinvamalai S. Dharmarajan, Hanbyul Choi, Nadia Hossain, Uthpala Munasinghe, Fehmida Lakhi, Dennisdhilak Lourdusamy, Somechukwu Onuoha, Padmavathi Murakonda, Anna Skokowska-Lebelt, Madhusudhana Kanagala, Robin O. Russell

Research output: Contribution to journalArticle

Abstract

Objectives: Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process. Design: As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process. Results: Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success. Conclusions and Implications: Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.

Original languageEnglish (US)
JournalJournal of the American Medical Directors Association
DOIs
StateAccepted/In press - Jan 1 2019

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Long-Term Care
Geriatrics
Polypharmacy
Drug-Related Side Effects and Adverse Reactions
Minerals
Analgesics
Deprescriptions
Quality of Life
Drug Costs
Proton Pump Inhibitors
Histamine Antagonists
Consultants
Ambulatory Care Facilities
Pharmacists
Vitamins
Pharmaceutical Preparations
Antidepressive Agents
Caregivers
Antipsychotic Agents
Comorbidity

Keywords

  • adverse drug events
  • Deprescribing
  • deprescribing as a performance improvement process
  • deprescription
  • medication discontinuation
  • polypharmacy

ASJC Scopus subject areas

  • Nursing(all)
  • Health Policy
  • Geriatrics and Gerontology

Cite this

Dharmarajan, T. S., Choi, H., Hossain, N., Munasinghe, U., Lakhi, F., Lourdusamy, D., ... Russell, R. O. (Accepted/In press). Deprescribing as a Clinical Improvement Focus. Journal of the American Medical Directors Association. https://doi.org/10.1016/j.jamda.2019.08.031

Deprescribing as a Clinical Improvement Focus. / Dharmarajan, Thiruvinvamalai S.; Choi, Hanbyul; Hossain, Nadia; Munasinghe, Uthpala; Lakhi, Fehmida; Lourdusamy, Dennisdhilak; Onuoha, Somechukwu; Murakonda, Padmavathi; Skokowska-Lebelt, Anna; Kanagala, Madhusudhana; Russell, Robin O.

In: Journal of the American Medical Directors Association, 01.01.2019.

Research output: Contribution to journalArticle

Dharmarajan, Thiruvinvamalai S. ; Choi, Hanbyul ; Hossain, Nadia ; Munasinghe, Uthpala ; Lakhi, Fehmida ; Lourdusamy, Dennisdhilak ; Onuoha, Somechukwu ; Murakonda, Padmavathi ; Skokowska-Lebelt, Anna ; Kanagala, Madhusudhana ; Russell, Robin O. / Deprescribing as a Clinical Improvement Focus. In: Journal of the American Medical Directors Association. 2019.
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