Deprescribing intervention reduced medication use among older adults in post-acute care

A pharmacist- or nurse practitioner-led deprescribing intervention successfully reduced medication use among hospitalized older adults who were discharged or transitioning to a post-acute care facility, data show.

Researchers said the intervention could help reduce the burden of polypharmacy in this population.

Eduard E. Vasilevskis, MD, MPH, an internal medicine specialist at Vanderbilt University Medical Center, and colleagues explained that while deprescribing is effective, gaps remain in research on deprescribing strategies for older hospitalized patients, who are vulnerable to adverse post-discharge outcomes.

“The majority of deprescribing interventions have been limited to specific drug classes or medical conditions. Few deprescribing interventions have considered the entirety of the medication list across the breadth of medical conditions,” they wrote in JAMA Internal Medicine. “Furthermore, fewer trials have initiated deprescribing in the hospital, and, to our knowledge, none of these trials have included patients needing continuing care in a post-acute care (PAC) facility.”

Vasilevskis and colleagues conducted a randomized clinical trial from March 2016 to October 2020 to analyze the safety and efficacy of the Shed-MEDs intervention. The analysis included 372 older adults (mean age, 76 years; 62% women) who were hospitalized and transitioning or being discharged to PAC facilities.

Of the study cohort, 284 were included in an intention-to-treat analysis. Among them, 142 were randomly assigned to the intervention and 142 were assigned to a control group.

The intervention was led by a nurse practitioner or pharmacist and included a review of medications, patient- or surrogate-approved deprescribing recommendations and deprescribing efforts that were started in the hospital and continued in the PAC facility. The control group received usual care.

The researchers found that, on average, participants in the intervention group had 14% fewer medications at PAC facility discharge (mean ratio = 0.86; 95% CI, 0.8-0.93) and 15% fewer medications 90 days after PAC facility discharge (mean ratio = 0.85; 95% CI, 0.78-0.92) compared with the control group.

The rates of adverse events, adverse drug events and adverse drug withdrawal events were similar between both groups, although there was “a consistent pattern toward lower rates in the intervention group,” Vasilevskis and colleagues wrote.

“For example, the most frequent adverse event was hospitalization, with 84 events in the intervention group and 107 in the control group,” they added.

The researchers acknowledged that the availability and training of clinicians is a barrier to deprescribing in the PAC setting.

“The efficacy of deprescribing in PAC would suggest the benefits of engaging clinical pharmacists or nurse practitioners with specific abilities to perform comprehensive medication reviews, identify opportunities to deprescribe, monitor symptoms, and provide patient and clinician education at the time of discharge,” they wrote.

Vasilevskis and colleagues concluded that future research is needed “to examine the effects of deprescribing on patient reported and additional long-term clinical outcomes.”