Adverse drug events occur frequently and cause substantial harm to patients. Even with these negative effects, medications with potential risks are often prescribed or continued despite lack of benefit. While efforts exist to prevent the initiation of medications with low likelihood of benefit to the patient, fewer attempts to reduce potentially inappropriate prescribing have been oriented towards discontinuation of a medication a patient is already taking. This de-implementation-based approach is known as deprescribing. An associated process is de-escalation, which is reducing the dose of a medication without complete cessation.
Though many clinical interventions are aimed at the provider or health care system, patients have a key role in their health care and may play an important part in deprescribing. Although some believe providers have primary responsibility for initiating deprescribing, patient initiation of discontinuation conversations can effectively facilitate deprescribing.
Aim 1 will assess the implementation outcomes of feasibility, acceptability, and appropriateness (to patients, providers, and staff) of two patient-activation informational brochures to facilitate deprescribing. Aim 2 will examine the pre-post effect of the patient-activation intervention by calculating the frequency of discussions about medication discontinuation, as well as assessing the proportion of encounters in which target medications were discontinued or de-escalated.
We propose a single-site mixed-methods pilot feasibility study of a patient-centered intervention. There will be two cohorts of Veterans, one composed of patients at risk of hypoglycemia and the other a group of patients that are chronically prescribed a proton pump inhibitor (PPI), with each receiving the applicable EMPOWER ("Eliminating Medications through Patient Ownership of End Results") brochure adapted to the VA population. We mail EMPOWER to patients scheduled for primary care clinic visits who may be eligible for deprescribing. Clinical providers will receive a brief informational intervention that complements the medication information provided to patients. We will use interviews and focus groups to assess the feasibility of the intervention and aspects of implementation that were successful, as well as those factors that need to be modified prior to conducting a broader implementation study. We will also conduct chart review to determine prevalence of deprescribing conversations during the intervention and medication deprescribing and de-escalation both before and during the intervention period.
Increasingly, VA and other health systems recognize the critical role of the patient as the ultimate end-user of health care and an essential participant in decision making. Stopping or reducing inappropriate medication has the potential to improve health care safety and efficiency by using fewer medicines and decreasing adverse drug events and their associated costly use of health care resources. Paring down medication regimens may also improve patients' adherence to remaining medications and increase quality of life.
- Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. Journal of general internal medicine. 2020 Nov 1; 35(11):3323-3332.