A nurse- or pharmacist-led deprescribing intervention at hospital discharge proved to be safe and effective at reducing total medication burden
In a randomised controlled trial, US researchers from Tennessee in the US found that a pharmacist or nurse-led patient-centred deprescribing intervention in older adults led to a significant reduction in medicine use compared to a control group.
Polypharmacy is usually defined by the use of five or more medicines and one US study showed that in 2010, among elderly patients (65 years and older), polypharmacy was present in 39% of cases. Polypharmacy regimes increase the risk of adverse drug reactions and somewhat alarmingly in one analysis of 2,105 older adults discharged from hospital, 74% were prescribed a polypharmacy regime. Consequently, deprescribing interventions to reduce medication burden are likely to decrease the risk subsequent adverse events associated with the use of multiple treatments. In the current study, the US team examined the effectiveness of a deprescribing framework at reducing medication burden. The intervention had been previously piloted in one centre and was found to be effective, leading to US to undertake randomised, controlled trial of the intervention. The intervention itself involved nurses or pharmacists reviewing the medicines of older adults prior to hospital discharge to a post-acute care (PAC) facility and the outcomes compared with the usual hospital discharge care. The primary outcome was the total medication count at hospital and PAC discharge and participants were followed-up for assessment, 90 days after being discharged from the PAC facility. Secondary outcomes included the total number of potentially inappropriate medications (PIMs) as well as the drug burden index (DBI) which measured sedative and anticholinergic burden.
Deprescribing intervention and total medication burden
A total of 284 participants (142 per group) with a mean age of 76.2 years (62% female) were included in the final analysis and the median length of PAC facility stay was 22 days. Overall, the median number of prehospital medications per patient was 16.
As a result of the intervention, participants were taking a mean of 14% fewer medications upon discharge from the PAC facility (mean ratio, MR = 0.86, 95% CI 0.80 – 0.93, p < 0.001). In addition, at the 90-day assessment, those previously assigned to the intervention were taking 15% fewer medicines (MR = 0.85, 95% CI 0.78 – 0.92, p < 0.001) compared to the control group.
The intervention group were also prescribed fewer PIMs and had a lower DBI after 90 days yet the incidence of adverse drug events was similar between the intervention and control groups (hazard ratio, HR = 0.83, 95% CI 0.52 – 1.30).
The authors concluded that their deprescribing intervention was both safe and effective at reducing overall medication burden and called for future studies to examine the impact of the intervention on both patient-reported and long-term clinical outcomes.
Vasilevskis EE et al. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute CareA Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023