Past Grantees and their Projects - US Deprescribing Research Network

2020 – 2021

Principal Investigator:

Sarah L. Szanton, PhD, ANP, FAAN – Johns Hopkins University

Grant planning award:

Goal Directed Deprescribing and its effect on Self-Management in Community-Dwelling Older Adults with Multiple Chronic Conditions

Existing medication reconciliation programs for older adults rarely leverage older adults’ purpose and life goals (not treatment goals) to ground treatment recommendations and behavior change. Existing programs also often fail to comprehensively serve patients across the cognitive function spectrum. The objective of this project is to plan, convene stakeholders and engage in human-centered design to develop a deprescribing intervention called GOALS which will optimize medication regimens based on the person’s (and family’s as indicated) functional goals. This planning period will allow us to develop study materials using stakeholder input and then to implement an open label pilot so that the next phase of pilot testing the novel self-management medication program will be feasible, effective, and practical. In Phase 1, we will interview 12-24 older adults, 17-24 clinicians (primary care prescribers, pharmacists, and registered nurses), and Medicare Advantage leadership until thematic saturation. We will also learn how to incorporate older adults and their family members onto the research team. After incorporating what we learned, the 2nd phase will be a small open label pilot of the intervention, GOALS, derived from adaptations to the CAPABLE and OPTIMIZE programs. The results of this grant will lead to a full pilot to test feasibility, acceptability, preliminary effect size and interest from stakeholders.

Co-Principal Investigator:

Ranjit Singh, MD, MBA – University at Buffalo

Co-Principal Investigator:

Robert Wahler, PharmD – University at Buffalo

Grant planning award:

Planning for NIA R21/R33 Grant- Patient Driven Deprescribing to Enhance Successful Aging

This is a grant planning award to a UB multi-stakeholder deprescribing (DeRx) group known as Team Alice. It has evolved from the Alice Story, a real case derived from the horrific death of Alice Brennan triggered by preventable medication errors and system failure. Team Alice consists of a growing number of academic, primary care, health plan, and regional health information system partners. The mission is to save people like Alice by pursing multiple strategies to deprescribe unsafe medication, reduce harm, and foster successful aging. During this USDeN Grant Planning grant, pre-requisites for the submission of a 5-year proposal to the National Institute on Ageing will be completed. It is built upon prior pilot work funded by the RRF Foundation for Aging that developed the Alice Story based videos to arm patients to pick up on danger signs and to drive the DeRx conversation with clinicians during care transitions. Team Alice is also built upon three interlocking stakeholder engagement strategies: (1) the Team Alice Elder Voices Network (patient driven DeRx); (2) the Team Alice Deprescribing Partnership (provider driven DeRx); and (3) the Regional Health Information Exchange Organization (cross-system DeRX capability). With this interlocking stakeholder framework, the larger study will use a Pragmatic Clinical Trial design to test the impact of the video intervention in primary care settings.

Principal Investigator:

Justin Lee, BScPhm, ACPR, MD, FRCPC – McMaster University

Pilot award:

Improving Medication Prescribing-Related Outcomes for the Vulnerable Elderly In Transitions (IMPROVE-IT): A Pilot Randomized Controlled Trial

The acute hospitalization and transitional care period is an unique opportunity to facilitate deprescribing. Polypharmacy is not only common in hospitalized older adults, but often exacerbated during hospitalization. Transitions in care are also vulnerable points for medication safety and healthcare delivery. With the aim of increasing rates of successful deprescribing and improving the health of hospitalized older adults, we will use EMR-integrated digital medication optimization tools and post-discharge virtual care to enhance identification of high-risk medication use and support patients at risk of medication-related harm. A team of pharmacists and specialist physicians will work with randomly selected high-risk patients and their healthcare team to minimize unnecessary or potentially harmful medications. This team will also provide post-discharge follow-up and monitoring using virtual care technology to continue the deprescribing plan. We will use the results of this pilot to optimize methods and evaluate whether it is feasible to conduct a larger study evaluating whether this model can safely reduce potentially inappropriate medication use, reduce the need to return to hospital, and improve quality of life in patients being discharged home from hospital.

Principal Investigator:

Sarah Vordenberg, PharmD, MPH – University of Michigan

Pilot award:

Psychological and Clinical Factors that Predict Intent to Deprescribe Medications Among Older Adults

Our research team seeks to learn more about factors that are important to older adults when they consider reducing or stopping a medication. We will do this by conducting two surveys each with 4,800 older adults across four countries (United States, United Kingdom, Netherlands, and Australia). Each participant will be asked to give their opinions on a hypothetical patient scenario that has been developed by our diverse team in partnership with our stakeholder organizations. In the first survey, we will examine how the reason for using the medication (e.g. preventing a disease or treating symptoms of a disease) as well as the reason for a recommendation to stop the medication (e.g. lack of benefit vs. potential for harm) influence older adults’ willingness to stop medications. In the second survey, we will examine how the type of medication (e.g. addictive or non-addictive medication) and whether the participant is making a recommendation about oneself (as if they were the patient in the case) or on behalf of the patient in the case (e.g., if it was their friend) influence their willingness to stop medications. We anticipate that our research will contribute to our understanding of how older adults make deprescribing-related decisions and will inform the development and evaluation of a patient-centered multi-level deprescribing intervention.

Principal Investigator:

Scott Pilla, MD, MHS – Johns Hopkins University

Pilot award:

A National Physician Survey of Perspectives on Deprescribing Diabetes Medications for Older Adults

The treatment of diabetes in older adults requires balancing the long-term benefits of lowering blood glucose levels with the potential adverse effects of diabetes medications, most notably hypoglycemia which can cause serious health consequences and lower quality of life. To reduce these harms, diabetes guidelines recommend deprescribing diabetes medications, especially when patients have a high risk for hypoglycemia. Despite this, diabetes medications are rarely deprescribed in clinical practice. Little is known about how physicians make decisions about deprescribing diabetes medications and the barriers that they face to achieving this. Therefore, the objective of this study is to conduct a national survey of physicians to understand their perspectives on deprescribing diabetes medications. We will first appoint a survey design team composed of stakeholders (physicians from multiple specialties, older adults with diabetes, caregivers for older adults with diabetes, pharmacists, and clinical leadership) who will participate in a series of meetings to develop and refine the survey. We will then mail the survey to a national sample of physicians in geriatrics, general internal medicine / family practice, and endocrinology, targeting at least 125 physicians per specialty. The findings from this study will be critical for understanding the low rates of deprescribing diabetes medications nationally, and for enhancing the safety of diabetes care in older adults through physician-targeted interventions, policy initiatives, and national guidelines.

Principal Investigator:

Joshua Niznik, PharmD, PhD – University of North Carolina, Chapel Hill

Pilot award:

Deprescribing Bisphosphonates in Nursing Home Residents with Dementia

Osteoporosis medications are prescribed to individuals at high risk for fracture with the goal of preventing these serious events that can result in loss of mobility and reduced quality of life. Although oral osteoporosis medications have been proven effective in strengthening bones and reducing fractures, they have also been linked to several side effects that may cause significant discomfort, including gastrointestinal upset, heartburn, and irritation of the esophagus. Older nursing home residents with dementia are a population with goals of care that in many cases are centered around comfort and symptom management. One can imagine that for these individuals, the benefits of fracture prevention may no longer outweigh the discomfort of adverse effects. Deprescribing is one strategy to reconcile medication use with goals of care. Studies have shown that the benefits of bisphosphonates may persist for up to 2 years after stopping therapy. Thus, deprescribing bisphosphonates may be an effective way to optimize medication use for nursing home residents with dementia by reducing the likelihood of burdensome side effects without completely losing their benefit. Unfortunately, prescribers are often hesitant to deprescribe medications as there are a limited number of studies that have examined what may happen to patients after stopping medications they may have been taking for long periods of time. Our study will evaluate real-world patterns of oral osteoporosis medication deprescribing in older nursing home residents with dementia. Our goal is to improve our understanding of how and why these medications may be deprescribed. Rather than conducting a clinical trial, which can be logistically difficult, we will use existing data from health insurance databases to describe patterns of deprescribing. This pilot project will lay the groundwork for future research to quantify the balance between the benefits and harms associated with deprescribing oral osteoporosis medications in older nursing home residents with dementia.