Deprescribing is a practice that all clinicians and pharmacists understand, yet guidelines on how and when a patient should stop taking a medication remain rare. The focus of this practice is to reduce or stop medications that may harm or no longer benefit a patient. When physicians can discontinue or decrease the number of medications a patient is prescribed, it both decreases the likelihood of an adverse event, and reduces the financial burden of paying for a multitude of medications.
How can health care providers get back to basics to stop the medications that may be unnecessary or even harm patients?
An innovative program out of Ottawa, Canada demonstrates how simplifying deprescribing can help providers incorporate the basics back into their routine.
During her session at the 2017 IHI National Forum, Hayley Burgess, PharmD, BCPP, CPPS, AVP, Clinical Pharmacy and Medication Safety, Clinical Services Group, HCA Healthcare, and her co-presenters shared how some US health care institutions have replicated Ottawa’s program. Using examples from HCA, Kaiser Permanente, and Ascension, the presenters demonstrated why these institutions made deprescribing their focus, the barriers they encountered and lessons they learned, and how to begin making a deprescribing plan of their own.
HCA has taken Ottawa’s model and worked with the Institute for Healthcare Improvement to help reduce the use of Proton Pump Inhibitors (PPIs) in their inpatient hospital setting. (PPIs are a class of drugs that reduce acid production in the stomach often used to treat conditions such as heartburn.) By using the antimicrobial stewardship model, the team created a step-by-step approach for decreasing PPI use.
“Telling stories with evidence-based literature helps bring to light the fact that there are opportunities for change,” says Burgess. “Our mantra is and remains: Putting patients first.” In HCA’s case, it was awareness of a powerful marketing campaign that helped physicians understand the origins of overprescribing PPIs. In the 1990s, a popular television commercial asked, “Have an upset stomach? Take the purple pill.” Focusing on deprescribing was necessary, given the evidence that PPIs are a risk factor for renal disorders and pneumonia, and there has been debate over increased risk of Clostridium difficile infections, among others. HCA has seen a marked decrease from 2015– 2017 as a result of this effort.
Any initiative of this kind must focus on physician engagement. While being sensitive to the reality that physicians have competing priorities and resource constraints, it is important to share, “Why are we doing this?”
A few ways to achieve this:
- Share — “Everyone is trying to do what’s best for their patients, but sometimes physicians need to see data that shows where their prescribing falls within a spectrum comprised of their peers. This illustration can help them better understand that, perhaps, they are an outlier,” says Burgess.
- Encourage — “Once they have the information, they can ask themselves, ‘Why would I be different?’ or ‘What barriers do I have?’” explains Burgess.
- Educate and Support — “Bring the physician into the initiative at the inception, allow for questions and discussion, and demonstrate commitment by asking, ‘How can we help you do this?’ Lastly, incorporate any changes within their workflow, so compliance doesn’t create extra steps,” says Burgess.
Deprescribing takes a village, and success will require all of us to embed a “less is more” concept into our cultures. “This process will improve patient safety, the quality of care, and have a lasting impact on the patient experience,” says Burgess.
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Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines
Pharmacy sessions at the IHI National Forum taking place December 9-12, 2018, in Orlando, FL, USA.