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 older persons living with frailty. 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.
About the Project
Prescribing or continuing non-beneficial medications in seriously ill and older patients living with frailty 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.
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
Downar, J., Muscedere, J. (February 2016). Des traitements qui ne soulagent pas. La Presse+
Downar, J., Muscedere, J. (December 2015). Dying patients may not get best care. Troy Media.
Whitty, R., Bhatt, P., Koo, E., Porter, S., Battu, K., Kalocsai, C., Delicaet, K., Wong, G., Wu, R., Bogoch, I., Downar, J. (October 2016). A Pilot Study of a MEdication RAtionalization (MERA) Intervention. 21st International Congress on Palliative Care, Montreal, QC.
Bhatt, P., Koo, E., Whitty, R., Porter, S., Battu, K., Kalocsai, C., Delicaet, K., Wong, G., Wu, R., Bogoch, I., Downar, J. (March 2016). A pilot study of a MEdication RAtionalization (MERA) Intervention. Hospice Palliative Care Ontario Annual Meeting.
Rationale: Approximately two-thirds of Canadian seniors are taking more than five medications regularly, and 30% of those over age 85 are taking more than 10 medications. The frail elderly are even more likely to be taking multiple medications, and those who do are at elevated risk of medication errors, medication interactions, adverse drug reactions and noncompliance.
Hypothesis: It is feasible, effective and acceptable to implement an in hospital multidisciplinary team (the Medication Rationalization team (MERA)) to review the medications of frail elderly patients and recommend changes to align them with patient’s goals.
Objectives: Develop MERA to review the medications of frail elderly patients and recommend changes to align them with their goals. To rationalize patient medications (i.e. stop non-beneficial medications and offer comfort medications) to improve quality of life while reducing costs and potential or real harm to frail elderly patients.
- A team of various healthcare professionals, including a pharmacist as the team leader, helped explain the need for drugs prescribed to very ill and older patients.
- The intervention stopped patients from taking an important number of drugs while in hospital and after leaving the hospital.
- The MEdication RAtionalization (MERA) approach was acceptable to patients, caregivers, and staff. At the same time, MERA played a role that is currently not done by other members of the care team.
Why was this study needed?
Many ill and older patients living with frailty in the hospital receive potentially inappropriate or harmful medications, and do not receive medications for symptoms of advanced illness. Reducing the number of inappropriate medications and prescribing appropriate comfort medications may improve quality of care and lower the cost of care for seriously ill and older patients living with frailty. While reducing inappropriate medications has been studied widely in the general population, there is very little research about this approach in patients nearing the end of life.
Suggestions on how these findings could impact frail older adults and/or their family caregivers and how this might be measured:
- Making sure that only important medications are being taken by patients can improve symptoms and reduce treatment and caregiver burden.
- The potential to use MERA at more sites and increase its ability to help very ill and older patients may be better if it was automated and integrated with other medication programs.
- We are currently testing an automated version of the MERA approach in general medical wards across Canada and are planning to study this in Long-Term Care.
Brief comment on type of study:
- Our study used a team of various healthcare professionals to review medications, deprescribe inappropriate medications, and prescribe appropriate comfort medications for very ill and older hospital patients living with frailty.
- The pilot study took place in one hospital.
- Participants were hospital patients at risk of dying within six months due to advanced age or known disease.
- The team reviewed medications and made recommendations based on guidelines.
- We were most interested in finding out if this team approach was feasible, acceptable, efficient, and effective.
- An interprofessional, pharmacist-led team was effective for rationalizing the medications prescribed to seriously ill and elderly medical inpatients. We stopped an important number of medications and the effect was observed after discharge.
- Our MEdication RAtionalization (MERA) approach was highly acceptable to patients, caregivers and staff alike, and played a role currently unfilled by other members of the care team.
Why was this study needed?
Many seriously ill inpatients, including those living with frailty, receive potentially inappropriate or harmful medications, and do not receive medications for symptoms of advanced illness. An effort to “rationalize” medications in the seriously ill and frail elderly, by deprescribing inappropriate medications and prescribing appropriate comfort medications, may simultaneously improve care while reducing costs. Deprescription has been studied extensively in the general medical population, but relatively little is known about this approach in patients nearing the end of life.
Suggestions on how administrators or policy maker could use the findings:
- More than half of the medications stopped came from one of five classes: lipid-lowering agents, proton pump inhibitors, vitamins/minerals, homeopathic/herbal supplements, and docusate. A time-efficient intervention could focus solely on these five medications/classes.
- We are currently testing an automated version of the MERA approach in randomized trial on general medical wards across Canada and are planning a national study of this approach in Long-Term Care.
- Once automated, the tool could be integrated with electronic health records to allow the MERA process to be part of existing workflow for pharmacists and physicians engaged in medication reconciliation at transfer or medication review in long-term care.
Brief comment on type of study in lay terms:
- Our objective was to study an interprofessional medication rationalization (MERA) approach to deprescribing inappropriate medications and prescribing appropriate comfort medications.
- We conducted a single centre pilot study of inpatients at risk of 6-month mortality from advanced age or morbidity.
- The MERA team reviewed medications and made recommendations based on guidelines.
- We evaluated our primary outcomes based on feasibility, acceptability, efficiency, and effectiveness.
Number of medications stopped, changed or added by the MERA team.
|Meds Stopped||Meds Changed||Meds Added|
Response of patients/family members to the MERA intervention
CFN Webinar (October 5, 2016): Pilot study of MEdication RAtionalization intervention