The report is a product of the VA/HSR&D Evidence Synthesis Program.
Deprescribing for Older Veterans: A Systematic Review
More than 40% of people in the United States age ≥65 years take five or more prescription medications on a regular basis to control or prevent disease symptoms and complications. The number of medications a person is taking may be the single most important predictor of adverse drug effects. Efforts have been underway for more than 30 years to develop and test interventions to mitigate the adverse effects of polypharmacy and inappropriate medication use. Initially, drug discontinuation efforts were focused on stopping specific medications considered to be problematic in older adults. This has evolved into a more holistic approach, called “deprescribing,” that considers medications in the context of the individual’s comorbidities, functional status, treatment goals, and life expectancy. Deprescribing has been defined as “the clinically supervised process of stopping or reducing the dose of medications when they cause harm or no longer provide benefit.”
Exposure to multiple medications, known as polypharmacy, is associated with increased risk of negative outcomes, such as falls, cognitive impairment and other geriatric syndromes, hospitalizations, and death. Further, about 50% of older adults are taking one or more potentially inappropriate medications (PIMs), including those without a clear indication, duplicative medications, and medications known to pose risks in the elderly.
The VA Center for Medication Safety in Aging was charged with the development and implementation of deprescribing approaches in VA settings. Commissioned by the National Center for Patient Safety and endorsed by VA Pharmacy Benefits Management and the Geriatrics and Extended Care Services, the purpose of this evidence review is to inform that work. Specific questions to be addressed included:
- What are the effectiveness, comparative effectiveness, and harms of deprescribing interventions among adults age 65 and older?
- What are the identified facilitators and barriers that impact the implementation of deprescribing interventions within large-scale health systems such as VA?
Investigators with VA’s Evidence Synthesis Program (ESP) Center in Minneapolis, MN searched MEDLINE®, EMBASE, the Cumulative Index of Nursing and Allied Health (CINAHL), and the Cochrane Library from 1990 to February 2019. The literature search identified 2,049 relevant articles; of these, 102 articles representing 86 trials were included in this review. The analyses focused on 38 trials from community or primary care settings. In addition, investigators did a supplemental literature search for studies reporting barriers and facilitators of implementation of deprescribing programs and included 9 studies reported in 10 papers.
Primary outcomes were quality of life/functional status, all-cause mortality, hospitalizations, falls, adverse drug withdrawal events, major adverse cardiovascular events, and delirium. Secondary outcomes included total number of medications discontinued, number of medications with dosage decreased, number of potentially inappropriate medications (PIMs) discontinued, number of medications added or substituted, adherence to medications, types of medications discontinued, medication burden, and cost.
Interventions were categorized as follows: Comprehensive Medication Review (CMR), Education (Provider or Patient Directed), Computer Decision Support, and Hybrid/Other.
Summary of Findings
Several options for deprescribing interventions may reduce the burden of polypharmacy and PIMs in community-dwelling older adults.
- Comprehensive Medication Review may reduce all-cause mortality (low certainty of evidence), PIMs, and costs compared to usual care.
- CMR might be feasible to implement, given the extensive presence of pharmaceutical expertise already embedded within VA ambulatory care clinics. In designing a program, consideration should be given to incorporating a plan for follow-up contact with patients after the initial CMR. Implementing CMR in a research context or as part of a quality improvement project would increase the evidence base from VA settings.
- Educational interventions (Provider or Patient Directed)
- A direct-to-consumer patient engagement program with targeted educational material provided directly to patients may reduce PIMs.
- Provider education without feedback had no significant effect on outcomes; however, when coupled with patient-specific feedback to the provider, it may reduce PIMs.
- Computer Decision Support, such as with electronic health record alerts and other clinical decision support systems, may reduce PIMs.
- Hybrid/Other Interventions may reduce falls and PIMs.
- There was no evidence of harms (adverse drug withdrawal events, worsening of medical conditions, or increased mortality, hospitalizations, or major adverse cardiovascular events) associated with any of the deprescribing interventions.
- No studies addressed the comparative effectiveness of the deprescribing interventions either within or across categories.
- Most studies were not designed to assess mortality, hospitalizations, delirium, falls, or major adverse cardiovascular events, and no studies reported on biomarker measures such as glycemic or blood pressure control.
Barriers and facilitators of implementation of CMR, educational, and computer decision support deprescribing interventions include:
- Patient (i.e., concerns about safety of alternative medication regimens, reluctance to give up medications);
- Prescriber (i.e., lack of knowledge, not believing in need for CMR); and
- System factors (i.e., lack of institutional support and resources, inadequate time).
Also of note, among the 38 trials included in this review, only 10 were conducted in the US, of which only 2 were conducted in VA.
Research Gaps/Future Research
The most glaring gap is the absence of comparative effectiveness trials. This is particularly important since the literature to date does not conclusively identify one deprescribing approach that is clearly superior to others. Since the VA Academic Detailing Service is planning to introduce VIONE, a medication management tool to reduce polypharmacy risk, this might be a good opportunity to acquire comparative effectiveness data. Consultation with implementation and quality improvement evaluation experts within VA Health Services Research & Development (HSR&D) to design a robust roll-out plan that varies key conditions across different sites would likely yield important insights into best practices.
Implications for VA Policy and Practice
De-intensification of medication -- "deprescribing" -- when risk of harm exceeds benefit is an important component of safe medication practice. This evidence synthesis shows that individualized medication review, patient and provider education, and computerized decision support can promote reduction in inappropriate medication use and improve outcomes important to older Veterans and their families. VA support of such approaches and efforts to overcome barriers to deprescribing could reduce inappropriate medication use and decrease adverse drug events among older Veterans.
Understanding the Experience of Veterans and VA Clinicians
In an effort to enhance the impact of findings from this systematic review, members of the Center to Improve Veteran Involvement in Care (CIVIC) collaborated with ESP to develop a web-based narrative companion product focused on portraying the experiences of Veterans and VA clinicians as they initiate and go through the deprescribing process. Researchers conducted 15 semi-structured interviews with 10 clinicians and 5 Veterans on their deprescribing experiences. An analysis of the interviews revealed several factors which lead to successful deprescribing, including:
- Clear communication about the reasons why deprescribing is needed,
- Shared decision-making,
- Understanding of patients’ health goals and preferences, and
- Commitment to work with Veterans over a sustained period of time.
Identified barriers included challenges with coordinating care, lack of patient understanding of risks associated with continued polypharmacy, and, sometimes, limited alternative treatment options. Based on the interview data, the research team developed two stories to illustrate the lived experiences from both Veteran and clinician perspectives. Researchers also created an “advice” page which highlights the themes identified that promote successful deprescribing efforts.
A Cyberseminar titled “ESP Report: A Systematic Review and Meta-Analysis of Interventions for Deprescribing in Community Dwelling Older Adults” will be held on April 21 from 12:00pm – 1:00pm ET. Register here.
Bloomfield H, Linsky A, Bolduc J, Greer N, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt, TJ. Deprescribing for Older Veterans: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2019.
To view the full report, go to http://vaww.hsrd.research.va.gov/publications/esp/deprescribing-sr.cfm (* This report is currently available on the intranet only. If you have intranet access, copy and paste the URL into your browser.)
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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