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CAT2017-10

A Collaborative Intervention for Streamlining Medication Appropriateness and Deprescribing within Integrated Healthcare Teams

Medications can help older adults, but can also harm them. A lot of visits to emergency rooms and hospitals are due to medications. Older adults living with frailty tend to have many health problems, but are at risk of harm from
medications. This makes it hard to get older adults the treatments they need and keep them safe from the harms from medications. Previous research has shown the benefits of stopping medications older adults no longer need. Even so, healthcare professionals do not do this as well as they could. This project's goal is to make a tool for pharmacists who work with doctors and nurses that will help older adults safely stop medications that are no longer needed. They will use knowledge and tools that are already known, and adapt them to put into practice.

In the first six months the project team, which includes older adults and their families, pharmacists, doctors, nurses, and healthcare policymakers will work together to develop a tool that pharmacists can use to help older adults stop medications that are no longer needed. In the remaining ten months, they will use the tool in primary healthcare teams and nursing homes.

Overall, we expect that by using the tool pharmacists will be able to help reduce the number of pills people take, reduce drug costs, reduce harms from medication use and improve quality of life for older adults living with frailty and their loved ones.

About the Project

Medication use is common in older adults living with frailty.  Polypharmacy is not a benign problem of many medications but represents an increased risk of adverse drug events, drug-related emergency department visits and hospitalization. Estimates suggest that in older adults approximately 40% of emergency department visits are drug-related. Once an individual has suffered a serious drug-related event their medications may be re-evaluated but this point in time is too late. Identification of individuals at risk of medication misadventure and subsequent deprescribing in a safe way should be the goal of care.  Primary care clinics are strategically positioned to identify frail individuals at risk for a drug-related adverse events and prevent the event before it happens by safely stopping the high-risk therapy.  

We propose the collaborative development of a simple intervention tool using the expertise of pharmacists, nurses, primary care physicians, geriatricians and caregivers engaged in care of older adults living with frailty.  This tool will identify and target deprescribing for older adults living with frailty using an approach that can used by pharmacists working in collaborative health teams (two in Nova Scotia, and two in New Brunswick).  The intervention will include frailty assessment. Using the tool, the pharmacists will initiate deprescribing and monitor their frail patients to successful deprescribing within their health care team. Nursing home patients are amongst the frailest of our seniors and polypharmacy is common in these environments. In addition to primary care sites the tool will be piloted in Nursing Home sites in New Brunswick and Nova Scotia.

We hypothesize that making positive changes to medication regimens by deprescribing in older adults living with frailty will have a number of benefits. The most obvious will be the reduced drug costs.  This is a relatively small cost savings but it can be a significant benefit to low income older adults. In addition, deprescribing can have a greater impact for public drug payers and the cumulative cost-avoidance could theoretically be reinvested into other health initiatives.  We also hypothesize that deprescribing will reduce medication misadventure which will lead to a reduction in emergency department visits and hospitalizations. This is where the most significant cost savings can be realized due to deprescribing activity.  These benefits will be able to be measured using drug cost data and through analysis of administrative databases such as the discharge abstract database.  We will capture the positive impact on patients which will include reduced drug use, reduced pill burden and hopefully improved quality of life.

Project Team

Principal Investigators:

Melissa Andrew, MD, PhD, FRCPC, Associate Professor, Geriatrician, Dalhousie University, Faculty of Medicine

Pamela Jarrett, MD, FRCPC, FACP, Associate Professor, Geriatrician, Horizon Health Network, New Brunswick, Dalhousie University

Jennifer Isenor, PharmD, Assistant Professor, Dalhousie University, College of Pharmacy and Faculty of Medicine

Co-Investigators:

Natalie Kennie-Kaulbach, PharmD, University Teaching Fellow, Dalhousie University, College of Pharmacy and Department of Family and Community Medicine

Carole Goodine, PharmD, AGE-WELL/NBHRF Post-doctoral Fellow, University of New Brunswick, York cCre Centre

Linda Yetman, RN, BN, Med, ACNP (dip), PhD, Research Coordinator, Horizon Health Network, St. Joseph’s Hospital, Department of Geriatric Medicine

Bryn Robinson, PhD, Clinical Research Manager, Horizon Health Network, Maritime SPOR SUPPORT Unit

James Ted McDonald, PhD, Director, New Brunswick Institute for Research, Data and Training; Professor, University of New Brunswick, Department of Economics

Rose McCloskey, RN, PhD, GNC (C), Professor, University of New Brunswick, Department of Nursing & Health Sciences

Collaborators:

Andrew Brilliant, BSc(Pharm), Pharmacist, Horizon Health Network

Julie Weir, RN, BN, MN, Assistant Director, Responsible for Clinical Care and Innovation, New Brunswick Association of Nursing Homes

Eden d'Entremont-MacVicar, BSc(Pharm), Pharmacist, Nova Scotia Health Authority - Queens Family Health

Heidi Liston, BSc(Pharm), PharmD, Director, Drug Utilization, Government of New Brunswick, Department of Health, Pharmaceutical Services

Tara Sampalli, MD, Director, Research and Innovation,  Assistant Professor, Medical Informatics, Nova Scotia Health Authority, Primary Health Care and Dalhousie University, Medical Informatics

Rick Gibson, MD, Senior Medical Director, Acting Chief, Nova Scotia Health Authority, Primary Health Care and Department of Family Practice

Kiera Rooney, BSc(Pharm), ACPR, Pharmacist, Nova Scotia Health Authority

Shanna Trenaman, BScH,BSc(Pharm), MAHSR, ACPR, PhD Student, Dalhousie Univeristy, Graduate Studies, Interdisciplinary PhD

Lisa Bedford, Manager, Dalhousie Family Medicine Clinics - Mumford and Spryfield sites, Nova Scotia Health Authority, Central Zone, Primary Health Care

Mary McNally, DDS, MSc, MA, Professor, Dalhousie University, Faculties of Dentistry & Medicine, Bioethics

Marjorie Willison, Dip. OT, MSc. Graduate Certificate Aging and Continuing Care

Project Contact: Melissa Andrew--melissa.andrew@nshealth.ca

CAT2017-10

Key words: Polypharmacy, Frail Elderly, Deprescribing, Ambulatory Care, Primary Care, Nursing Homes, Pharmacists, Collaboration, Interprofessional Relations, Geriatric Assessment