A pilot study of a MEdication RAtionalization (MERA) Intervention
The MERA pilot investigated a system change that applied existing knowledge about medication effectiveness to improve care for the seriously ill and frail elderly. Pending the results of the pilot study, the MERA intervention could be easily scalable and transferable to other institutions, and would be appropriate for a larger, randomized study.
Findings: Overall, the MERA team made a total of 246 recommendations, with at least one recommendation for 52/54 patients (96%). Of these recommendations 90% were accepted by the attending team, and 95% of those recommendations were also accepted by the patient/substitute decision-maker. Overall, MERA recommendations resulted in the discontinuation of 160 medications (mean 3.0 per patient), dose changes for 48 medications (mean 0.9 per patient), and the addition of 13 medications (mean 0.2 per patient). The MERA team is a feasible and highly acceptable intervention for both patients and medical staff, and results in important changes to medication prescription for seriously ill and frail elderly medical inpatients. We identified important system-level barriers to the deprescription and MERA process, which can be used to inform future interventions. We plan to develop means of automating the MERA process to allow more widespread adoption (see CFN grant CAT2015-TG2).
Impact of findings: It was found that the inhospital MERA team was a feasible and highly acceptable intervention for both patients and medical staff, and that MERA recommendations led to important medication changes. Inappropriate medications are burdensome to patients, and may be very time consuming for nurses to prepare. The financial costs of this behaviour can be staggering, and medication costs are often partially borne by patients themselves. The MERA recommendations led to important medication changes which ultimately may improve patient care and comfort. The MERA process is labor intensive and thus it would be more feasible and easier to disseminate broadly if it could be automated. More than half of the recommendations involved only 5 medications or medication classes, suggesting that even a very simplified algorithm could still have substantial impact. We have begun the process of incorporating our process into a computerized algorithm that would be more feasible for medical wards with fewer pharmacy staff and this algorithm will be used in a large, multicentre, CIHR funded study beginning in 2017.
Publications, presentations and webinars
About the Project
Prescribing or continuing non-beneficial medications in seriously ill and frail elderly patients is potentially harmful, costly and time-consuming; and failing to offer comfort medications to symptomatic patients nearing the end of their life is tantamount to neglect. Many hospitals already employ pharmacy‐focused quality improvement projects such as medication reconciliation and antibiotic stewardship, which have led to significant improvements in patient safety and reductions in cost.
We conducted a pilot study of an innovative MEdication RAtionalization (MERA) team on the General Medical Inpatient ward. The MERA team included members of multiple disciplines (medicine, pharmacy, nursing) that met regularly with admitting physicians to review the medications prescribed for any patient meeting specific age and illness criteria. The team reviewed the rationale for each medication, recommended discontinuing any non‐comfort medication that has no clear short-term benefit to the patient (e.g. statins) and suggested adding orders for comfort medications (e.g. opioids, sedatives) as needed. The summary recommendations were proposed to the patient or substitute decision-maker, and changes were made only with their consent.
For more details on the project rationale, hypothesis and objectives, click here.
James Downar, MDCM, MHSc, FRCPC -- University Health Network
Kiran Battu, BScPhm, RPh -- University Health Network
Isaac Bogoch, MD, FRCPC -- University Health Network
Kendra Delicaet, MA -- University Health Network
Sandra Porter, BScPhm, RPh -- University Health Network
Gary Wong, BScPhm -- University Health Network
Peter Wu, MD, FRCPC -- University Health Network
Robert Wu, MD, MSc, FRCPC -- University Health Network
Knowledge Users and Partners:
Toronto General and Western Hospital Foundation
University Health Network (Department of Pharmacy Services)
Project Contact: James Downar -- firstname.lastname@example.org