Sara Battar, MD, CAVHS Associate Chief of Staff for Geriatrics and Extended Stay Services, discusses the keys for living a long and healthy life with WWII Veteran Herman Shirley. Source: Central Arkansas Veterans Healthcare System.
BUTLER, PA — Polypharmacy, the concurrent use of multiple and often unnecessary medications, poses significant health risks to patients, including frailty, hospital admissions, falls and even mortality.
A new study published in the Journal of the American Pharmacists Association shows the implementation of a pharmacist-led, systemwide initiative in the primary-care setting utilizing the VIONE dashboard significantly reduced polypharmacy in one VA medical center.1
VIONE—which stands for Vital, Important, Optional, Not indicated and Every medication has an indication—is a tool designed to identify patients with polypharmacy and provide a framework for deprescribing medications across VHA facilities. The dashboard, which was developed by researchers at the Central Arkansas Veterans Health Care System in Little Rock, assigns a VIONE risk score that takes into account comorbidities, age, risk scores/screening tools, acute events or healthcare utilization and specific active medication characteristics.
“This score reflects a patient’s risk level for polypharmacy-related adverse events,” said Emily Rea, PharmD, clinical pharmacist practitioner at the VA Butler, PA, Health Care System and first author of the new study.
To evaluate the impact of a deprescribing initiative in the primary-care setting utilizing the VIONE dashboard, Rea and her colleagues began with interdisciplinary education with the primary-care teams involved (primary-care providers such as physicians, pharmacists and nurses) to garner support for the project and spread awareness of the importance of limiting polypharmacy, she said. Next, using the VIONE dashboard, they identified patients with 15 or more active medications for inclusion in the project.
Beginning with those deemed at highest risk, patients were offered the prescribing service by a clinical pharmacy technician. Enrollment ended when a target population of 60 patients was met.
Upon enrollment, the clinical pharmacy technician performed a medication reconciliation to optimize the time spent later between pharmacist and patient, Rae said. A clinical pharmacist practitioner (CPP) then completed a comprehensive chart review and subsequently held an appointment with the patient either in person, over the phone or with a video call to discuss potential deprescribing options. Recommendations were relayed to the primary-care provider (PCP) for final approval and communicated to the patient by the pharmacy team.
Discontinued Medications
The initiative’s impact was measured by the number of discontinued medications, the acceptance rate of recommendations by the PCP, the potential annualized cost avoidance and the number of patients referred to CPP medication-management clinics.
The results, including the following, were largely positive.
- Within the patient population, 352 medications were deprescribed, with an average of 5.6 medications per patient. The annualized cost avoidance (the estimated cost that would accumulate over a year if the medication remained active based on the price per unit dispensed) was $184,221.
- The acceptance rate by PCPs involved was high, at 96.7% . “A large portion of visits—36.5%—were with patients who had previous medication-management enrollment with CPP within primary care, which could have contributed to a high number of patients being willing/interested in enrollment for this project due to having pre-project rapport or trust with the CPP,” Rea said.
- As a result of the appointment, 25.4% of patients were referred to pharmacist-led clinics for ongoing disease state management, for disease states including diabetes, hypertension and COPD.
The study demonstrated that it is possible to add a fully pharmacist-led deprescribing service into primary care in an entire healthcare system, said Rae. It further showed that “addition of this service allowed for the expansion of pharmacy-led services and a statistically significant reduction in VIONE risk scores in the enrolled patients between preimplementation and post-implementation,” she said.
The main drawback of the initiative was that it was time-consuming, she said. “The time spent on chart review—72.3 plus or minus 23.9 minutes—and appointments—31.6 plus or minus 9.6 minutes—was the most notable weakness as it went over the originally allotted and expected time.”
Rae said the service will continue at the VA Butler Healthcare System as a consult service or utilized for population management. “The PCP will enter a consult requesting a polypharmacy review and the CPP will complete the review and provide recommendations to the PCP,” she said. “If necessary, the CPP will get involved for an appointment for thorough counseling and/or medication management on an as-needed basis. For population management, the CPP can identify patients and perform a chart review and/or appointment as their schedule allows.”
She noted that the initiative at VA Butler Healthcare System is a model for how other VA locations could use the dashboard to reduce polypharmacy. “This dashboard is being used across the country at many different VA locations,” she said. “The dashboard can be utilized in different ways. The method can be tailored to the site based on time and resources available in order to best fit how that location sees best to use it. This project is one option for how it can be used.”
VIONE was developed by Sarah Swathy Battar, MD, associate chief of staff for Geriatrics and Extended Care Services at Central Arkansas VA. Last November, she accepted the Gold Austco Excellence Award for Quality and Patient Safety at the 45th World Hospital Congress of the International Hospital Federation. She accepted the award on behalf of the Michael E. DeBakey VAMC in Houston.
- Rea E, Portman D, Ioannou K, Lumley B. A healthcare system-wide, pharmacist-driven deprescribing initiative in the primary care setting. Journal of the American Pharmacists Association. 2023 Sep:S1544-3191(23)00298-4. doi: 10.1016/j.japh.2023.09.003. PMID: 37722503.
