How should we better measure the cost-effectiveness of deprescribing interventions? Recommendations for improving value assessment
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: Suggestions for improvement [published online ahead of print, 2023 Feb 21]. J Am Geriatr Soc. 2023;10.1111/jgs.18298. doi:10.1111/jgs.18298 Despite the well-established link between deprescribing interventions and reduced use of potentially inappropriate medications (PIMs), there is little evidence behind the cost-effectiveness of these interventions. Eight members of the USDeN Junior Investigator Intensive (JII) program joined forces to publish a commentary on value assessment of deprescribing interventions, published in the Journal of American Geriatrics Society last month. Authors provide an overview of cost-effectiveness analyses (CEAs), a standard approach to deprescribing value assessment. Most CEAs report value as cost per quality-adjusted life years (QALYs), while some report cost per PIM stopped or per increase in the medication appropriateness index. These approaches are limited by short time windows and their lack of relevance to a variety of patient-centered outcomes. Our JII members
Key learnings from the OPTIMIZE deprescribing pragmatic trial
Sheehan OC, Gleason KS, Bayliss EA, et al. Intervention design in cognitively impaired populations-Lessons learned from the OPTIMIZE deprescribing pragmatic trial [published online ahead of print, 2022 Dec 12]. J Am Geriatr Soc. 2022;10.1111/jgs.18148. doi:10.1111/jgs.18148 Polypharmacy is a growing concern among older adults, especially those with cognitive impairment and Multiple Chronic Conditions (MCC). Cognitively impaired older adults may face additional challenges with medication management and adherence. While many older adults with cognitive impairment are open to having medications deprescribed, few deprescribing interventions have included this population. The OPTIMIZE cluster randomized pragmatic trial explored how educating and activating patients, family members, and clinicians about deprescribing affected the number of potentially inappropriate medications and number of chronic medications. The patients were older adults with dementia or mild cognitive impairment (MCI) and MCC. The patient/family caregiver intervention component involved deprescribing brochures that were mailed to patients 2 weeks prior to a primary care
Multiple Comorbidities and Multiple Medications: The Challenges Facing Older Adults with Heart Failure
Kwak MJ, Cheng M, Goyal P, et al. Medication Complexity Among Older Adults with HF: How Can We Assess Better?. Drugs Aging. 2022;39(11):851-861. doi:10.1007/s40266-022-00979-2 Heart failure affects 6 million Americans today, over half of whom are 75 and older. Older adults with heart failure face complex medication regimens that are further complicated by the cognitive, physical, and social challenges of aging. Older adults taking multiple medications are at greater risk of adverse drug events, medication errors, drug-drug or drug-disease interactions, and nonadherence. Few studies, however, have assessed the complexity of medications or clinical outcomes among older adults with heart failure. USDeN Pilot Awardee Dr. Min Ji Kwak led a review of heart failure medication management, covering medication regimen complexity assessment, outcome assessment, and the representation of older adults in the literature. Nine research articles on medication complexity among heart failure patients were included in the literature view. Assessment of Medication
How “age-friendly” are deprescribing interventions?
Wang J, Shen JY, Conwell Y, et al. How “age-friendly” are deprescribing interventions? A scoping review of deprescribing trials [published online ahead of print, 2022 Oct 11]. Health Serv Res. 2022;10.1111/1475-6773.14083. doi:10.1111/1475-6773.14083 The 4Ms (“Medication,” “Mentation,” “Mobility,” and “What Matters Most”) are considered essential components of age-friendly health systems. Age-friendly health systems are better equipped to handle the most pressing health concerns facing older adults. Given that over a third of older adults use potentially inappropriate or unnecessary medications (PIMs), effective, patient-centered deprescribing interventions are expected to incorporate the 4Ms of age-friendly care. After conducting a scoping review of deprescribing trials, a team mentored by USDeN pilot core leaders Amanda Mixon and Sandra Simmons found that “Mentation,” “Mobility,” and “What Matters Most,” are considered to varying degrees in the intervention design and outcome assessment. In this review, 37 studies were selected for their focus on specific deprescribing interventions and inclusion
Deintensifying diabetes medications: Beliefs and misconceptions among older adults￼
Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications [published online ahead of print, 2022 Sep 29]. J Gen Intern Med. 2022;10.1007/s11606-022-07828-3. doi:10.1007/s11606-022-07828-3 While previous studies have examined the patient perspective on deprescribing, few have explored this topic in relation to diabetes medications. Guidelines recommend deintensification of diabetes medications for older adults with type 2 diabetes who are below glycemic target where it can reduce polypharmacy or the risk of adverse drug effects. In practice, however, diabetes medications are rarely stopped or reduced regardless of glycemic control or health status. In hopes of optimizing deintensification, researchers at Johns Hopkins set out to understand the patient perspective on stopping or reducing diabetes medications. They conducted a qualitative study using individual semi-structured interviews of 24 older adults with medication-treated type 2 diabetes and good glycemic control. Interviewers
Gabapentin as a substitute for opioids: Is the solution creating new problems?
Bongiovanni T, Gan S, Finlayson E, et al. Prolonged use of newly prescribed gabapentin after surgery [published online ahead of print, 2022 Aug 24]. J Am Geriatr Soc. 2022;10.1111/jgs.18005. doi:10.1111/jgs.18005 Postoperative pain management has changed significantly in the last decade. Surgeons have attempted to decrease opioid prescribing by using non-opioid “multimodal” pain regimens, such as gabapentinoids (gabapentin and pregablin). While gabapentinoids are associated with reduced postoperative pain and opioid consumption, they are still included in the AGS Beers Criteria list as potentially inappropriate medications (PIMs) for older adults in certain contexts. In addition, closer attention must be paid to the proper discontinuation of gabapentinoids when they are no longer needed for post-operative pain control. Prolonged use of gabapentinoids carries its own unique risks, from altered mental status to other adverse events and hospitalizations. Researchers from UCSF and Yale investigated the predictors of prolonged gabapentin use through a retrospective cohort study
The Tool to Reduce Inappropriate Medications (TRIM): Can a clinical decision support tool promote deprescribing among primary care clinicians?
Mecca MC, Zenoni M, Fried TR. Primary care clinicians’ use of deprescribing recommendations: A mixed-methods study. Patient Educ Couns. 2022;105(8):2715-2720. doi:10.1016/j.pec.2022.04.013 The Tool to Reduce Inappropriate Medications (TRIM) provides individualized reports on patient medications, including medication reconciliation errors and potentially inappropriate medications (PIMs). A recent study published in Patient Education and Counseling explored the impact of TRIM reports on primary care clinicians’ medication communication and deprescribing practices. While clinicians who received TRIM reports performed more robust medication reconciliation and were more likely to discuss treatment intensity, medication non-adherence, and poor cognition, these clinicians were not more likely to deprescribe or deintensify medications. Deintensification usually happened in response to a patient’s adverse event rather than in response to TRIM recommendations. In addition, medication reconciliation elements of the TRIM report led to more medication discussion than parts of the report that delineated potentially inappropriate medications. Despite increased discussion among clinicians and patients
Can N-of-1 trials inform deprescribing practices? Dr. Parag Goyal weighs in
Goyal P, Safford M, Hilmer SN, et al. N-of-1 Trials to Facilitate Evidence-Based Deprescribing: Rationale and Case Study [published online ahead of print, 2022 Jun 15]. Br J Clin Pharmacol. 2022;10.1111/bcp.15442. doi:10.1111/bcp.15442 Junior Investigator Intensive scholar Parag Goyal and a team of researchers recently published a narrative review on deprescribing-N-of-1 trials. N-of-1 trials compare treatment effects in an individual patient by following the same patient over multiple time periods, a clinical trial subtype known as ‘multiple-period crossover design experiments.’ While N-of-1 trials are typically used to compare medication class or dosage, the therapeutic precision associated with this type of trial is also well-suited to deprescribing research. Deprescribing-N-of-1 trials provide evidence on the impact of continuing or stopping treatment in an individual patient. Individual-level evidence may allay patient and physician concerns about discontinuing medication and involve the patient in the clinical decision-making process. Additionally, N-of-1 trials may evade the time constraints
Survey finds that Willingness to Deprescribe is Linked to Health Outcome Priorities
Green AR, Aschmann H, Boyd CM, Schoenborn N. Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey [published online ahead of print, 2022 Jun 6]. J Am Geriatr Soc. 2022;10.1111/jgs.17917. doi:10.1111/jgs.17917 A team led by Dr. Ariel Green, who received a pilot award from the US Deprescribing Research Network, recently published a clinical investigation in JAGS on the association between willingness to deprescribe and health outcome priorities among older adults. A 2020 cross-sectional survey of older adults’ responses to two scenarios informed this study: Preventive medicine scenario: Respondents are asked about their willingness to deprescribe a statin being used for primary prevention that may cause side effects such as muscle pain or weakness, nausea, constipation, diarrhea, and drug interactions. Symptom-relief medicine scenario: Respondents are asked about their willingness to deprescribe a sedative-hypnotic being used for insomnia that may cause side effects
All about Outcomes: USDeN Panel Weighs in on Defining, Selecting, and Applying Deprescribing Intervention Outcomes
Bayliss, EA, Albers, K, Gleason, K, et al. Recommendations for outcome measurement for deprescribing intervention studies. J Am Geriatr Soc. 2022; 1- 11. doi:10.1111/jgs.17894 The US Deprescribing Research Network’s very own Measures Workgroup recently published recommendations for selecting and using outcomes for deprescribing interventions in the Journal of the American Geriatrics Society. Authors point to discrepancies in outcome definitions as a barrier to high quality evidence on the impact of deprescribing. Inconsistent evidence slows the translation of findings into clinical practice. Through a scoping review of the deprescribing literature, authors identified common outcome measures from 107 deprescribing studies. An expert panel, 12 members from the workgroup with expertise in deprescribing research as well as primary care, geriatrics, pharmacology, and implementation science, convened nine times to discuss outcome measures in the literature. The panel had three goals: To identify common deprescribing measures and outcome definitions To prioritize outcome categories for future
USDeN Call for Pilot Studies Preparatory to Large Clinical Trials
Complementary and Integrative Health Interventions to Support Deprescribing of Benzodiazepine Receptor Agonists in Older Adults The US Deprescribing Research Network (USDeN) will soon be seeking applications for large pilot studies that test complementary and integrative health approaches to support deprescribing of benzodiazepine receptor agonists in older adults. The goal of this program is to support pilot studies that will test study procedures, refine interventions, assess feasibility, and other such activities such that by the end of the one-year pilot study the investigators will be well-positioned to apply for a large grant to conduct a definitive clinical trial of the interventions. Pilot studies will be awarded with a budget of up to approximately $160,000 over one year. For more information, visit our Grants Opportunity page, and reach out to [email protected]
Describing deprescribing: How do GPs discuss deprescribing topics with their patients, and how in-depth do they go?
Thompson W, Jarbøl D, Nielsen JB, Haastrup P, Pedersen LB. GP preferences for discussing statin deprescribing: a discrete choice experiment. Fam Pract. 2022;39(1):26-31. doi:10.1093/fampra/cmab075 Although there is ample evidence on the benefits of deprescribing for older patients, providers’ deprescribing-related communication preferences are less understood. Given that clinicians often have the greatest influence on patients’ deprescribing decisions, it is crucial for researchers to understand clinician preferences. Former USDeN Junior Investigator Intensive (JII) scholar Dr. Wade Thompson and his team at the University of Southern Denmark narrowed in on the preferences of general practitioners (GPs) in Denmark, who are responsible for the majority of prescribing for Danish patients. The study team conducted a discrete choice experiment (DCE), which required participants to choose between alternative discussions with hypothetical patients. The DCE involved statin treatment and assessed GPs’ preferred discussion length (‘no discussion,’ ‘brief discussion,’ or ‘detailed discussion’) for four different topics: goals of