June 3rd, 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 new blog series, Deprescribing Champions, we are highlighting some of ways in which clinicians are making a positive impact at their institutions. (You can read previous profiles of Dr. Brandon Combs and Dr. Emily McDonald on our website.) Our latest edition features advice from four pharmacists, all of whom are affiliated with Lifespan/Rhode Island Hospital:
Dr. Andrew Zullo, PharmD, PhD, Assistant Professor at Brown University, Research Fellow at the Providence VA Medical Center, and Pharmacist at Lifespan/Rhode Island Hospital; Dr. Laura McAuliffe, PharmD (Clinical Pharmacist Specialist), Dr. Marci Wood, PharmD (Year 2 Resident in Ambulatory Care), and Dr. Allison Zuern, PharmD (Year 2 Resident in Ambulatory Care).
Together, these pharmacists answered our questions about the culture of prescribing and clinical pharmacists’ role in deprescribing.
Lown Institute: How big of an impact does institutional culture have on prescribing?
Zullo et al: My colleagues and I have often found unexplained variation in prescribing in many of our research studies of older adults. Institutional culture is one of the most likely explanations for the variation.
The effect of institutional culture is particularly apparent in hospitals, which can affect both prescribing and deprescribing. In hospitals where providers believe that hospitalization is a key opportunity to modify and improve patients’ medication regimens, the health care team adopts a culture of doing more adjusting of medications. In other hospitals, providers believe that medications should not be tampered with. They believe that the hospitalization is a unique circumstance and the information upon which medication changes would be based (such as laboratory values or blood pressure) is unlikely to represent the patient’s circumstances once they return home or to another post-acute setting.
So, for example, a patient with chronic obstructive pulmonary disease (COPD) may be admitted to the hospital with a COPD exacerbation. Some providers will hesitate to prescribe a new medication or change the maintenance inhaler regimen because they believe that these are “outpatient issues” that should be dealt once the patient is discharged and follows up with their primary care physician or pulmonologist. Other providers will consider the hospitalization a clear opportunity to modify the inhaler regimen or prescribe a new drug. Ultimately, institutional culture often drives these decisions when good research and strong evidence are unavailable to inform providers about which is the best approach.
How have you made an impact in your institution?
One way that we have made an impact at our institution is by implementing more interdisciplinary team work to discuss patient cases and help providers 1) to recognize circumstances in which it is likely appropriate to modify medication regimens, and 2) to feel more comfortable with making changes to the medication regimens.
Do you have any stories about how these care teams led to change in prescribing?
We recently had an interesting case where a patient was on several pain medications, including meloxicam, ibuprofen, lidocaine patches, tramadol, and acetaminophen. The patient was also using cannabidiol (CBD) oil, which is a supplement, not a medication. Interestingly, the patient stated that only the CBD oil was helping with their pain and it was their strong preference to continue using it, but not the pain medications. Even though the patient was not taking any of the other pain medications that were prescribed, the medical resident was hesitant to deprescribe them. Our pharmacy team was able to successfully advocate for deprescribing and highlight the importance of the patient’s stated preferences. We reasoned that if the patient continued to experience pain, the deprescribing of the other pain medications would not only help to inform later decision-making about what treatments to reinitiate or newly prescribe for pain, but also help to ensure that the patient had an accurate list of what treatments they were using and found effective.
What advice would you give for other attendings or leaders for how to promote a culture of deprescribing at their institution?
First, consider incorporating pharmacists and other allied health professionals into the care team if you haven’t already. Pharmacists and other team members can certainly help to collect, review, and analyze medication information to identify potential drug interactions and therapeutic duplication (when a patient is on multiple of the same type of drug), and to inform clinicians of possible nonadherence. More importantly, they can help incorporate patients’ preferences as a key criterion in the care team’s prescribing and deprescribing decisions.
Second, we recommend incorporating processes into the clinical workflow that prompt providers to regularly ask about and record patients’ health care beliefs, values, and goals for care, particularly as they may change over time. Creating advisories in electronic health records is one approach to doing that as long as the prompts are carefully designed to avoid alert fatigue. Regularly asking patient their preferences often has the added benefit of improving the accuracy of the health record as well.
The bottom line: Incorporate pharmacists on the care team and regularly elicit patients’ preferences to help promote a culture of deprescribing.