Part two of our Patient Safety Week series will highlight an ongoing study on deprescribing that is being led at St. Paul’s by two CHÉOS Scientists, Drs. Anita Palepu and Nadia Khan. Part one explained what polypharmacy is and work from Rita McCracken. You can read part one here.
Drs. Anita Palepu and Nadia Khan, CHÉOS Scientists and internists at St. Paul’s Hospital, are co-investigators on a clinical study that is tackling polypharmacy. The trial is testing MedSafer, an electronic tool that facilitates medication review and identifies potential opportunities for deprescribing. St. Paul’s is one of 11 sites from 7 universities across Canada that is participating in the study, which is funded through a CIHR project grant and supported by the Canadian Frailty Network.
“The study is really around medication safety, reducing burden, and more rational treatment,” explained Dr. Palepu. “We saw this as an opportunity to see if this electronic tool would be helpful in prompting care providers to deprescribe or at least flag medications that are potentially inappropriate for patients.”
MedSafer’s algorithm uses a patient’s active diagnoses and medications to make recommendations about potential prescription changes and provides advice to guide physicians in the deprescribing process. The study will assess how effectively MedSafer reduces adverse drug events after patients are discharged from the hospital and how it performs in prompting prescription changes and other metrics of patient safety and well-being.
Though there are various indices and tools to identify specific medications that are potentially inappropriate, there were few resources to systematically guide the deprescribing process. MedSafer builds off of the initial work of researchers in B.C., including CHÉOS Scientist Dr. Rita McCracken, who contributed to the development of the web application MedStopper, which aimed to fill that gap. MedSafer was developed based on feedback from pilot testing of MedStopper and the current trial will provide a more rigorous assessment of the tool. One change that emerged from the feedback was to modify the name to better reflect the intent of the intervention, which is not about simply cutting off medications.
“When you say you’re going to stop a medication there’s an abrupt sense of ‘oh no, what’s going to happen’” explained Dr. Palepu.
Both patients and providers may be wary about stopping medications, having an if-it’s-not-broken-don’t-fix-it attitude, which is a barrier to engaging in medication reviews. For this reason, MedSafer is reframing what deprescribing is about.
“The application is not designed to make you stop a medication, it’s to make practitioners think about its safety. There may be a good reason why the patient is on a medication. It’s really about digging deeper and not making assumptions.”
“One great advantage is that all of our teams have a pharmacist assigned which allows us to be explicit about thinking about the medications,” she said. “It will be interesting to see if anything changes. Perhaps for hospitals where they don’t have pharmacists that are engaged in this type of care this tool will be really helpful.
Dr. Palepu also pointed out the benefit that paring down a patient’s medication can have on treatment adherence and ultimately treatment effectiveness.
“I’m always trying to think about the medication burden because we know that the more medicines people are prescribed the less likely they are to be taking them, because of A) cost, B) side effects, or C) because they just don’t want to,” said Dr. Palepu.
Currently, the St. Paul’s site is in the recruitment and control phase of the study. Drs. Palepu and Khan are assisted by Anne Chisholm, a CHÉOS research assistant, who is responsible for recruiting eligible patients who are 65 years or older and on at least 5 medications. Ms. Chisholm collects data from patient on their comorbidities, level of frailty, and medications which is then input into MedSafer. The study will be entering the intervention phase in the new year. Once that happens, the care team will receive a print out of prioritized and individually tailored deprescribing recommendations indicating medications that may be inappropriate, why they might be inappropriate, and how they can be safely stopped. The care team will review these recommendations to implement as they see fit and forward the information to patients’ family physicians. Thirty days after discharge participants will have a follow-up interview to check in with whether they have had any adverse events, seen a physician, and identify any changes in their medications.
Finally, safety and number of prescriptions aside, MedSafer can be viewed as a step toward enhancing patient-centred care by encouraging a dialogue between physicians and patients about their treatment plan.
“MedSafer is a prompt to have more shared care decision making and to talk with patients about why they’re on a medication, if they really need it, if we can try a lower dose,or stop it. It’s not to tell you what to do,” noted Dr. Palepu. “We are asking people what’s really important to you, what are your goals, and how can we prioritize.”
More information on the MedSafer trial can be found here.