2018 Issues   /   Pharmacy

Surveys Show Why VA Good Prescribing Practice Also Should Include Deprescribing

By U.S. Medicine

Amy Linksy, MD, MSc, of the VA Boston Healthcare System said VA patients sometimes complain that taking too many drugs is a burden. Photo from Twitter
BOSTON — For years, physicians have had one primary question about the medications they prescribe: Will the patient take them? But, now, as awareness of the dangers of polypharmacy increases, more clinicians struggle to determine the best way to discontinue prescriptions.

“We know there are benefits of reducing polypharmacy. If you have someone stop taking a medication that is no longer beneficial to them; you reduce their risk of harms from the medication. If you reduce the number of medications someone takes, you increase their adherence,” said Amy Linsky, MD, MSc, of the VA Boston Healthcare System.

“Many veterans talk about the burden of taking so many medications and how taking multiple medications on various cycles makes them feel sicker and older,” she said.

A recent review conducted by European researchers added to the advantages of supervised medication discontinuation enumerated by Linsky. “Deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs,” according to an article in the European Journal of Internal Medicine.1

Research on deprescribing focuses on “what is the best way to stop or taper a medication and how to know when a medication’s risk exceeds it benefits for a specific patient,” Linsky explained. Preferences for Interventions to Improve Ability to Deprescribe Medications

Linsky and her colleagues have researched the challenges of deprescribing from both the provider and patient perspective. In the abstract, everyone agrees that discontinuing medications that are outdated, not indicated, causing adverse effects or of limited benefit compared to their risk makes sense, but “there is little guidance to clinicians about how to integrate the process of deprescribing into the workflow of clinical practice,” they noted in a study of provider preferences published in BMC Health Services Research.2

Changing the habits of providers and expectations of patients can require more work than continuing to prescribe a medication that may no longer provide a benefit. A number of factors might compound the challenge, including patient complexity, clinical uncertainty and shared patient management.

Unclear Indications

The biggest issue for many prescribers is lack of clarity about why a patient was initially prescribed a particular medication. Previous research found that up to 30% of medications had an unclear indication in the patient’s chart, and the likelihood that the rationale for the prescription would be lost increases with the number of providers and healthcare systems involved in a patient’s care and the number of medications the patient takes. Further, certain medications, such as the anticonvulsant gabapentin and the antidepressant amitriptyline, are used off-label up to 80% of the time, which makes determining the original prescriber’s intent even more difficult, the Boston researchers wrote. In light of those statistics, the top choice of VA providers asked by Linsky and her colleagues to rank the interventions or system changes that would help them make the decision to deprescribe is not surprising. “Regardless of provider characteristics, the top-ranked choice was to have an indication for use on the prescription,” Linsky told U.S. Medicine.

The team conducted a web-based survey of 2,475 physicians, nurse practitioners, physician assistants and clinical pharmacy specialists who provide primary care in the VA. They received responses from 326.

Prescribers also wanted other members of the Patient Aligned Care Team (PACT) to help with follow up for patients during deprescribing. In the Boston team’s qualitative survey, many clinicians expressed a desire for something “similar to what we have when starting a blood pressure medication. Patients come in more often and other members of the team—pharmacists or nurses—check on them.”

At the VA, team check ups that rely on regular monitoring by pharmacists have been effectively implemented in warfarin and diabetes clinics and other cases.

Providers also want more conversation with patients about their medications, a discussion that could be facilitated by printing the indication for each prescription on the bottle or other packaging.

Patients shared some of the same interests, according to a second survey conducted by the Boston researchers. They mailed a survey that measured to 1,600 veterans who receive care through the VA and take five or more medications, and 803 veterans responded.3

Veterans who had previously discontinued a medication were also generally more interested in deprescribing and in shared decision-making and had higher levels of educational attainment than veterans who had not discontinued a medication. They were also more likely to have asked or been told to stop a medication. Patients who had a higher number of prescriptions, greater trust in their providers and consulted with a clinical pharmacist within the VA were less likely to discontinue their medications.

1Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Euro J Intern Med. March 2017;38:3-11.

2Linsky A, Meterko M, Stolzmann K, Simon S. Supporting medication discontinuation: provider preferences for interventions to facilitate deprescribing. BMC Health Serv Res. 2017;17:447.

3Linsky A, Simon SR, Stolzmann K, Meterko M. Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration. Published online ahead of print Oct 27, 2017.

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