A team of Vanderbilt University Medical Center researchers tackling the polypharmacy challenge are in the final year of the largest acute care deprescribing trial to date. Results will reveal the impact of mindful prescription review and intervention as older patients leave acute care to go to a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR).
The researchers previously showed as many as 83 percent of these older patients are prescribed 10 or more medications. Geriatric patients taking five or more medications (defined as polypharmacy) are at increased risk of geriatric syndromes such as delirium, cognitive impairment, depression, weight loss and falls.
Ed Vasilevskis, M.D., who serves as section chief of hospital medicine at Vanderbilt, and Sandra Simmons, Ph.D., director of Vanderbilt Center for Quality Aging, are leading the NIA-sponsored Shed-MEDS study.
“Once a patient’s acute care crisis has passed, there is a systemic tendency to lose sight of many of the underlying conditions that may affect recovery and ongoing quality of life,” Vasilevskis said. “Adding on prescription drugs is a primary case in point that may accelerate with multiple physicians and facilities in play.”
Shed-MEDS is a randomized, controlled trial comparing outcomes between deprescribed and control cohorts. All subjects are polypharmacy patients over age 50 discharged from Vanderbilt’s adult hospital to an SNF or IPR.
A clinical pharmacist or geriatric NP is assigned to review medications prior to discharge. “We spend a lot of time constructing what we call a ‘best possible medication history’ because we consider all medications the patient is taking, including over-the-counter medications, when identifying targets for deprescribing,” Simmons said.
“Once a patient’s acute care crisis has passed, there is a systemic tendency to lose sight of many of the underlying conditions that may affect recovery and ongoing quality of life.”
The pharmacist or NP makes recommendations to the patient or caregiver making medical decisions and consults with the other providers to make agreed-upon adjustments. They then follow up at three touchpoints: via phone seven days after transfer and again 60 days later, and with an in-person visit at 90 days. “We’ve had to change the home visit to a call during the pandemic,” Simmons noted.
The primary study endpoint is change in total number of medications. The secondary endpoint is the impact of medication reductions on adherence, geriatric syndromes and functional health status.
Dose reductions are considered successful deprescribing. “Our goal is to identify opportunities to stop or lower the dose or frequency of drugs where clinical evidence and patient preferences support this,” Vasilevskis said.
Toward a Lower Error Rate
Polypharmacy increased from 8.2 percent to 15 percent between 1999 and 2012. Among the 45 percent of older hospitalized patients discharged to SNFs with polypharmacy, the researchers emphasize more than 90 percent take at least one inappropriate medication.
Medication errors commonly occur because patients remain on a drug that was appropriate during their hospital stay or continue a pre-hospitalization drug that has been replaced by another. Reviewing a patient’s medication list at acute care intake can be fraught with complications, Vasilevskis says, and is often a secondary priority. In the handoff to an SNF or IRF, opportunities for global review may fall under the radar.
“Passing the Rx baton with careful attention toward ensuring the right list is compiled is an inherent goal of the Shed-MEDS research,” Vasilevskis said. “By developing systematic means of assuring this, we can help patients and contribute to more effective use of health care resources.”
Other Vulnerable Populations
The team is leading a similar study, Drug Reduction for Older Patients, funded by the Veterans Administration (VA DROP). Simmons says that while they’re targeting the same patient population, they are purposefully including SARS-CoV-2-positive and homeless veterans in the VA study.
“Passing the Rx baton with careful attention toward ensuring the right list is compiled is an inherent goal of the Shed-MEDS research.”
“In this population, we’re seeing that living conditions and other factors are playing an important role and that there are often other things we need to address before a Veteran returns home – the social determinants of health,” Simmons said. “Beyond addressing their medications, we’re connecting them with mental health and other VA resources to support their care.”
Simmons and Vasilevskis hope to extend Shed-MEDS to follow patients longer and see which medications might be added back and why. In addition to the two clinical trials, Vanderbilt is also part of a national deprescribing network (USDeN) with the University of California-San Francisco and Johns Hopkins Medicine.