Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks.

INTRODUCTION: Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED: Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION: Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.

Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER).

BACKGROUND: Polypharmacy, particularly among older adults, is gaining recognition as an important risk to health. The harmful effects on health arise from disease-drug and drug-drug interactions, the cumulative burden of side effects from multiple medications and the burden to the patient. Single-disease clinical guidelines fail to consider the complex reality of optimising treatments for patients with multiple morbidities and medications. Efforts have been made to develop and implement interventions to reduce the risk of harmful effects, with some promising results. However, the theoretical basis (or pre-clinical work) that informed the development of these efforts, although likely undertaken, is unclear, difficult to find or inadequately described in publications. It is critical in interpreting effects and achieving effectiveness to understand the theoretical basis for such interventions. OBJECTIVE: Our objective is to outline the theoretical underpinnings of the development of a new polypharmacy intervention: the Team Approach to Polypharmacy Evaluation and Reduction (TAPER). METHODS: We examined deprescribing barriers at patient, provider, and system levels and mapped them to the chronic care model to understand the behavioural change requirements for a model to address polypharmacy. RESULTS: Using the chronic care model framework for understanding the barriers, we developed a model for addressing polypharmacy. CONCLUSIONS: We discuss how TAPER maps to address the specific patient-level, provider-level, and system-level barriers to deprescribing and aligns with three commonly used models and frameworks in medicine (the chronic care model, minimally disruptive medicine, the cumulative complexity model). We also describe how TAPER maps onto primary care principles, ultimately providing a description of the development of TAPER and a conceptualisation of the potential mechanisms by which TAPER reduces polypharmacy and its associated harms.

Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy.

BACKGROUND: Polypharmacy is associated with poorer health outcomes in older adults. Other than the associated multimorbidity, factors contributing to this association could include medication adverse effects and interactions, difficulties in managing complicated medication regimes, and reduced medication adherence. It is unknown how reversible these negative associations may be if polypharmacy is reduced. The purpose of this study was to determine the feasibility of implementing an operationalized clinical pathway aimed to reduce polypharmacy in primary care and to pilot measurement tools suitable for assessing change in health outcomes in a larger randomized controlled trial (RCT). METHODS: We randomized consenting patients ≥ 70 years old on ≥ 5 long-term medications into intervention or control groups. We collected baseline demographic information and research outcome measures at baseline and 6 months. We assessed four categories of feasibility outcomes: process, resource, management, and scientific. The intervention group received TAPER (team approach to polypharmacy evaluation and reduction), a clinical pathway for reducing polypharmacy using "pause and monitor" drug holiday approach. TAPER integrates patients' goals, priorities, and preferences with an evidence-based "machine screen" to identify potentially problematic medications and support a tapering and monitoring process, all supported by a web-based system, TaperMD. Patients met with a clinical pharmacist and then with their family physician to finalize a plan for optimization of medications using TaperMD. The control group received usual care and were offered TAPER after follow-up at 6 months. RESULTS: All 9 criteria for feasibility were met across the 4 feasibility outcome domains. Of 85 patients screened for eligibility, 39 eligible patients were recruited and randomized; two were excluded post hoc for not meeting the age requirement. Withdrawals (2) and losses to follow-up (3) were small and evenly distributed between arms. Areas for intervention and research process improvement were identified. In general, outcome measures performed well and appeared suitable for assessing change in a larger RCT. CONCLUSIONS: Results from this feasibility study indicate that TAPER as a clinical pathway is feasible to implement in a primary care team setting and in an RCT research framework. Outcome trends suggest effectiveness. A large-scale RCT will be conducted to investigate the effectiveness of TAPER on reducing polypharmacy and improving health outcomes. TRIAL REGISTRATION: clinicaltrials.gov NCT02562352 , Registered September 29, 2015.

Linking Patients' Goals and Priorities to Recommendations for Medication Changes in a Polypharmacy-Focused Structured Clinical Pathway.

Polypharmacy is associated with poorer health outcomes in older adults. It is challenging to minimize the harmful effects of medications while maximizing benefits of single-disease-focused recommendations. Integrating patient input can balance these factors. The objectives are to describe the goals, priorities, and preferences of participants asked about these in a structured process to polypharmacy, and to describe the extent that decision-making within the process mapped onto these, signaling a patient-centered approach. This is a single-group quasi-experimental study, nested within a feasibility randomized controlled trial. Patient goals and priorities were mapped to medication recommendations made during the intervention. Overall, there were 33 participants who reported 55 functional goals and 66 symptom priorities, and 16 participants reported unwanted medications. Overall, 154 recommendations for medication alterations occurred. Of those, 68 (44%) recommendations mapped to the individual's goals and priorities, whereas the rest were based on clinical judgment where no priorities were expressed. Our results signal this process supports a patient-centered approach: allowing conversations around goals and priorities in a structured process to polypharmacy should be integrated into subsequent medication decisions.

People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study.

BACKGROUND: The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use. METHODS: This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data. RESULTS: We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice. INTERPRETATION: Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study.

BACKGROUND: The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups. METHODS: This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health-related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale. RESULTS: The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health-related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits). INTERPRETATION: From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.

Team approach to polypharmacy evaluation and reduction: study protocol for a randomized controlled trial.

BACKGROUND: Polypharmacy in older adults can be associated with negative outcomes including falls, impaired cognition, reduced quality of life, and general and functional decline. It is not clear to what extent these are reversible if the number of medications is reduced. Primary care does not have a systematic approach for reducing inappropriate polypharmacy, and there are few, if any, approaches that account for the patient's priorities and preferences. The primary objective of this study is to test the effect of TAPER (Team Approach to Polypharmacy Evaluation and Reduction), a structured operationalized clinical pathway focused on reducing inappropriate polypharmacy. TAPER integrates evidence tools for identifying potentially inappropriate medications, tapering, and monitoring guidance and explicit elicitation of patient priorities and preferences. We aim to determine the effect of TAPER on the number of medications (primary outcome) and health-related outcomes associated with polypharmacy in older adults. METHODS: We designed a multi-center randomized controlled trial, with the lead implementation site in Hamilton, Ontario. Older adults aged 70 years or older who are on five or more medications will be eligible to participate. A total of 360 participants will be recruited. Participants will be assigned to either the control or intervention arm. The intervention involves a comprehensive multidisciplinary medication review by pharmacists and physicians in partnership with patients. This review will be focused on reducing medication burden, with the assumption that this will reduce the risks and harms of polypharmacy. The control group is a wait list, and control patients will be given appointments for the TAPER intervention at a date after the final outcome assessment. All patients will be followed up and outcomes measured in both groups at baseline and 6 months. DISCUSSION: Our trial is unique in its design in that it aims to introduce an operationalized structured clinical pathway aimed to reduce polypharmacy in a primary care setting while at the same time recording patient's goals and priorities for treatment. TRIAL REGISTRATION: Clinical Trials.gov NCT02942927. First registered on October 24, 2016.

Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis.

BACKGROUND: Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS: We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS: Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION: Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

Identifying subgroups and risk among frequent emergency department users in British Columbia.

Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.

'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety.

BACKGROUND: This study explored the perspectives and experiences from patients and families around how patient/family preferences and priorities are considered in medication-related discussions and decisions within the healthcare system. METHODS: We conducted a qualitative study using focus groups with residents of Southern Ontario and British Columbia (N = 16). Three focus groups were conducted using a semi-structured focus group guide. The audiotaped focus group discussions were transcribed verbatim. A thematic analysis, using inductive coding, was completed. RESULTS: A total of three main themes [and several sub-themes (and sub-sub-themes)] emerged from the data: patient and family expertise [lived experience, information expert, and perceived expert roles (patient/family, healthcare provider)], perceived patient-centredness (relationship qualities of healthcare provider and assumptions about patients), and system (time, coordination and communication, and culture). Stories told by participants helped to clarify the relationships between the themes and sub-themes, leading to, what we understand as shared decision-making around medications and subsequent health outcomes. CONCLUSIONS: Our findings showed that shared decision-making resulted from both recognition and integration of the personal expertise of the patient and family in medications, and perceived patient-centredness. This is broadly consistent with the current conceptualization of evidence-based medicine. The stories told highlight the complex, dynamic, and nonlinear nature of shared decision-making for medications, and that patient priorities are not as integrated into shared decision-making about medications as we would hope. This suggests the need for developing a systematic process to elicit, record, and integrate patient preferences and priorities about medications to create space for a more patient-centred conversation.

Strategies to promote public engagement around deprescribing.

Many seniors remain unaware that certain medications may be harmful, despite high rates of polypharmacy and inappropriate medication use among community-dwelling older adults. Patient education is an effective method for reducing the use of inappropriate medications. Increasing public awareness and engagement is essential for promoting shared decision-making to deprescribe. The Canadian Deprescribing Network was created to address the lack of a systematic pan-Canadian initiative to implement deprescribing among older Canadians. The Canadian Deprescribing Network deliberately included patient advocates in its organization from the outset, in order to ensure a key strategic focus on public awareness and education. In this paper, we present the processes and activities rolled out by the Canadian Deprescribing Network as a blueprint model for engaging the public on deprescribing. Embedded within the structure of the network, the subcommittee on public awareness and engagement implements an action plan that includes needs assessments, population surveys, focus groups, deprescribing fairs, national stakeholders' meetings, public lectures and monthly exchanges with community champions and seniors' organizations. Educational materials and online media have been developed based on the answers to the questions: what information do seniors need about deprescribing? who should this information be delivered to? who needs to deliver the message? and how should seniors be engaged in deprescribing? In conjunction with seniors' organizations, members of the Network have iteratively refined key deprescribing messages, disseminated information about deprescribing, engaged the press and created a grass roots-driven public awareness and education campaign across Canada. Over 3000 seniors and seniors' organizations are involved, with over 25,000 educational tools being distributed across the country.

How's Your Health at Home: Frail Homebound Patients Reported Health Experience and Outcomes.

We used a web-based mixed methods survey (HowsYourHealth - Frail) to explore the health of frail older (78% age 80 or older) adults enrolled in a home-based primary care program in Vancouver, Canada. Sixty per cent of eligible respondents participated, representing over one quarter (92/350, 26.2%) of all individuals receiving the service. Despite high levels of co-morbidity and functional dependence, 50 per cent rated their health as good, very good, or excellent. Adjusted odds ratios for positive self-rated health were 7.50, 95 per cent CI [1.09, 51.81] and 4.85, 95 per cent CI [1.02, 22.95] for absence of bothersome symptoms and being able to talk to family or friends respectively. Narrative responses to questions about end of life and living with illness are also described. Results suggest that greater focus on symptom management, and supporting social contact, may improve frail seniors' health.

An Ecological Approach to Reducing Potentially Inappropriate Medication Use: Canadian Deprescribing Network.

Polypharmacy is growing in Canada, along with adverse drug events and drug-related costs. Part of the solution may be deprescribing, the planned and supervised process of dose reduction or stopping of medications that may be causing harm or are no longer providing benefit. Deprescribing can be a complex process, involving the intersection of patients, health care providers, and organizational and policy factors serving as enablers or barriers. This article describes the justification, theoretical foundation, and process for developing a Canadian Deprescribing Network (CaDeN), a network of individuals, organizations, and decision-makers committed to promoting the appropriate use of medications and non-pharmacological approaches to care, especially among older people in Canada. CaDeN will deploy multiple levels of action across multiple stakeholder groups simultaneously in an ecological approach to health system change. CaDeN proposes a unique model that might be applied both in national settings and for different transformational challenges in health care.