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From the hospital to the postacute care facility: How well is Shed-MEDS working?

Vasilevskis EE, Shah AS, Hollingsworth EK, et al. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med. 2023;183(3):223-231. doi:10.1001/jamainternmed.2022.6545

Despite the well-known risks of polypharmacy among hospitalized older adults, few deprescribing interventions target initiating deprescribing in the hospital, and to date no deprescribing trial has included older adults transitioning to a post-acute care (PAC) facility. Both acute care and PAC settings provide ample opportunities for deprescribing medications and monitoring deprescribing-related outcomes. To address this gap in deprescribing research, a team of investigators led by USDeN collaborator Eduard E. Vasilevskis conducted a randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention between 2016 and 2020. The intervention was carried out by trained research clinicians who began the deprescribing protocol in the hospital and continued to follow up with patients for the duration of the PAC facility stay and up to 90 days after discharge. The primary objective of the trial was to reduce the number of medications at both hospital discharge and PAC facility discharge, and for this reduction to persist up to 90 days after PAC discharge. The secondary objective of the trial was to determine the effect of the intervention on number of potentially inappropriate medications (PIMs) and anticholinergic and sedative drug burden using the Drug Burden Index (DBI).

142 participants were in the intervention group (Shed-MEDS) and 142 participants were in the control group (usual care). The treatment effect was statistically significant, with participants in the intervention group taking a mean of 14% fewer medications at PAC facility discharge and 15% fewer medications at the 90-day follow-up time compared to the control group (P<.001 for both outcomes). Intervention and control group members were prescribed a similar number of PIMs at hospital discharge (9.3 vs 8.8), but intervention group members were prescribed significantly fewer PIMs at PAC facility discharge and during the 90-day follow-up period. DBI was significantly lower for the intervention group at hospital discharge (mean difference –0.28), PAC discharge (mean difference –0.60), and during the 90-day follow-up (mean difference –0.35). The rate of adverse events was comparable between the groups (hazard ratio 0.83, 95% CI 0.52-1.30), although the study was underpowered to detect small to medium-sized differences in this outcome.

Study findings support the safety and efficacy of a clinician-led, patient-centered deprescribing protocol aimed at hospitalized older adults transitioning to a PAC facility. The sustained impact of Shed-MEDS following PAC facility discharge shows promise for future deprescribing interventions.

Primary author Dr. Vasilevskis shares his hope for future deprescribing interventions:

With regards to future trials, I think it is important that we continue to validate our findings in other acute care settings, including those in the community hospitals. Furthermore, our trial demonstrated the potential value of post-acute care as a site of intervention, and continued work engaging post-acute care partners will be important.  Finally, our trial was labor intensive, and new increasingly pragmatic approaches will be needed to enhance adoption and sustainability.

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