June 12th, 2019
The Lown Institute’s recent report, Medication Overload: America’s Other Drug Problem, highlights the harm to older Americans from the increasing use of multiple medications. Over the past several months, the Lown Institute has convened working groups of patients, doctors, nurses, advocates, researchers, and pharmacists to develop a “National Action Plan for Addressing Medication Overload,” which will be published in early 2020.
In this blog series, Deprescribing Champions, we are highlighting some of these working group members, who are role models for deprescribing, to show how they are making an impact at their institutions.
Our latest profile is of Dr. Maisha Draves, family medicine physician and Medical Director for Pharmacy at the Pemanente Medical Group. (Read our previous profiles featuring Dr. Emily McDonald, Dr. Brandon Combs, and Dr. Andrew Zullo and colleagues!)
Lown Institute: How did you first become interested in deprescribing?
As a family medicine physician at The Permanente Medical Group caring for a panel of patients, I get to know them over time. I’ve had the pleasure of practicing for 15 years with the same panel. I’ve watched them age and develop new medical conditions. There are times I have been surprised at how many medications one of my patients was taking. It happens often that people come in with symptoms, and as we work them up it becomes apparent that a medication or combination of medications is having a greater harm than benefit, compared to when the medication was originally prescribed. For example, I’ve had patients come in feeling dizzy, and we recognize that the blood pressure medication they’re taking has become too strong for them.
As part of an integrated health care model with an electronic health record, we can see all the medications that have been prescribed for a patient and more easily identify potential conflicts. Part of the Permanente Medicine philosophy is to make clinical decisions with our patients. I’ve also been happy to see that when a patient and I have sat together and simplified their medications, it makes them feel better. Watching this journey in my patients is what got me interested in polypharmacy and deprescribing.
How have your habits and preferences in medicine been shaped by institutional culture?
I’ve had the good fortune of practicing in institutions with strong academic cultures, where we continue to receive very good Continuing Medical Education (CME). At Kaiser Permanente, we are always looking at new guidelines and updates in clinical evidence, which often shapes the way we practice. More recently, our geriatrics group began to have conversations more overtly about what to do when a medicine that had benefit no longer has a benefit for the patient, and how to deprescribe.
Does it help that Kaiser is a closed system in which the health plan, hospitals, and medical groups are all integrated?
In our integrated system, our medical groups work very closely with our pharmacy and quality groups. We’re always looking to lead, to deliver the best care and highest quality care. As polypharmacy as a potential risk has become more understood, we’ve embraced bringing deprescribing into our practice. We work collaboratively with physicians and pharmacies to discuss goal therapies, discuss which medications may be causing harm, and work with patients to deprescribe one medication at a time (either through dose reduction or taking off medications). Our goal is to deliver the best quality care to the patient, and ensuring that all partners are driving toward that together.
How has Kaiser helped raise awareness about medication overload and change the culture of prescribing?
At Kaiser Permanente, we truly began with an awareness campaign with stakeholders. We started first with evidence-based literature searches that informed a small campaign to really engage the major stakeholders and departments within the system, to all acknowledge the problems of polypharmacy and our need to address it. At a group level, the education and awareness, along with stakeholder engagement was key.
Gathering evidence has been a big part of the effort to raise awareness about deprescribing. There’s been an inkling all along that too many medications are probably harmful, and an acknowledgment that hypoglycemia (low blood sugar) in older patients is harmful. At an individual level, I think everyone understands. But without evidence from more patients, it’s hard to get consensus and craft solutions.
In 2016, we began a study of deprescribing in selected anti-diabetic medications, in people over age 75 with well-controlled type 2 diabetes. We showed that older patients had a sustained benefit in hemoglobin A1c even when stopping some of their diabetes meds, and reduced their risk of morbidity and mortality. We presented the results in 2019 and they will be published soon.
Many of us were quite enlightened and excited to see these outcomes at a more population level, and with patients who were not coming in to see us with traditional symptoms that would cause us to take a look. We were able to identify patients who were hypoglycemic before they showed any symptoms. It showed that we can help prevent adverse events through deprescribing. Solutions that are backed by evidence showing positive outcomes can generate buy-in and enthusiasm. This one study is an indicator; much more research is needed on deprescribing.
Even with motivation and resources, many clinicians and institutions report that deprescribing is difficult. What have been some of the challenges making deprescribing more routine at Kaiser?
Even in our integrated system, this is a journey that we’re still on. We’re still actively engaged in awareness of the problem. Right now we’re working on widespread awareness in all of our clinical practices that too many pills can be harmful.
The biggest opportunity is the need for solutions, both in our own system and nationally. We have a lot of good evidence around the problem — we know that polypharmacy is associated with adverse drug events, drug-drug interactions, and non-adherence. What we still need is research around what solutions work and what solutions are going to fit in different models of care, and which solutions are practical for our health care systems and providers to implement. We are trying to come up with solutions, test them, and put together a research agenda to make sure the policies we put in place really drive to the benefit we’re seeking.
What would you tell a younger clinician or student who wants to be a champion for deprescribing at their institution but doesn’t know where to start?
I would say, at a group level, to work on education and awareness, and to get stakeholder support as soon as possible. On an individual level, it’s about really looking at each patient, their medication list, and each new prescription with a focus on both the benefits and risks.