How electronic tools can help deprescribe in the hospital
Can doctors effectively deprescribe — stop or reduce the dose of unnecessary or potentially harmful medications — when patients are in the hospital? Hospitalization can be a good opportunity to reduce the preventable adverse drug events that are common after discharge, and reconcile patients’ regular medications with any new ones they are given in the hospital.
However, deprescribing in the hospital can be difficult, since hospital clinicians are usually focused on patients’ acute care issues rather than long-term medication problems. They also may not have the training or support needed to prioritize medications for deprescribing or engage in a prescription checkup with patients.
That’s where clinical decision tools like Medsafer come in. Medsafer is an electronic tool developed by a team of Canadian researchers that helps guide physicians and pharmacists through the depresribing process. The software inputs information on patients’ medications, health conditions, and frailty, and gives clinical teams a set of medications that could be deprescribed for that patient. This goes a long way toward automating the deprescribing process.
To test how well this tool works on the ground, the Medsafer team conducted a randomized controlled trial with about 5,700 older adults at 11 hospitals in Canada. They found that compared to the control group, patients with clinical teams that used Medsafer were nearly twice as likely to have at least one medication deprescribed. About 30% of patients in the control group had a medication deprescribed, compared to 55% of patients in the intervention group.
Among the most commonly deprescribed drugs in the trial were sleep aids, pain relievers, stool softeners, diabetes medications, blood thinners, and antipsychotics. Patients in the intervention group had much higher rates of deprescribing for risky meds like benzodiazepines (40% vs 20%), codeine and tramadol (55% vs 34%), antipsychotics (34% vs 23%), and diabetes meds (50% vs 36%), compared to those in the control group.
Despite the impressive rate of deprescribing using Medsafer, the study found no significant difference in adverse drug events within 30 days of discharge between the intervention and control groups. This could be because many of the drugs deprescribed were not beneficial to patients but not particularly risky (stool softeners or cholesterol medications, for example).
However, that doesn’t mean that deprescribing these drugs has no benefit. “Deprescribing these medications is less likely to impact 30-day ADEs, but still has patient and societal value, such as avoiding excess cost, waste, and pill burden,” the authors of the study wrote.
The results also point to the need for measuring outcomes besides short-term ADEs in deprescribing research. As UCSF geriatrics professor Dr. Michael Steinman wrote on Twitter, “We need to move beyond ADEs as our main (& often only) way of addressing medication harms. People experience harms from meds in lots of other ways. Cost burdens. Medicalization of lifestyle. Fear of future harms. Impacts on social functioning.”
Reducing unnecessary meds can also help patients achieve their long-term health goals. In a recent research letter in JAMA Internal Medicine, researchers at Beth Israel Deaconess Medical Center found that nearly 20% of adults with hypertension take medications that raise their blood pressure, such as antidepressants, NSAIDS, steroids, and estrogens. Patients taking these medications were more likely to need to take antihypertensive drugs to counteract these effects. Finding opportunities to deprescribe could make it easier for these patients to get their blood pressure under control.