What’s New in the Patient Safety World
May 2015
Hospitalization: Missed Opportunity to Deprescribe
Among our numerous columns
on potentially inappropriate medication use in the elderly, we’ve done a few
specifically on deprescribing (see our Patient Safety
Tips of the Week for March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly” and
September 30, 2014 “More
on Deprescribing”).
We always recommend
that you do a “brown bag” medication reconciliation at least annually with all
your geriatric patients in which you determine all the medications a patient is
taking, including OTC drugs and supplements. The same can be done in a
Medication Therapeutic Management (MTM) session with a pharmacist or nurse in
other settings. You will always be surprised how many drugs are found to be
duplicative or no longer necessary or potentially inappropriate and the
opportunity to “deprescribe” presents itself.
But a new study from Australia points out that we often miss another ideal opportunity for deprescribing: the inpatient hospitalization (Hubbard 2015). They looked at patients aged 70 years or older admitted to general medical units of 11 acute care hospitals and, not unexpectedly, found that polypharmacy and hyperpolypharmacy were prevalent. However, significantly, they found that despite identification of multiple medications that might be considered potentially inappropriate almost no changes were made in the number or classification of medications.
Hubbard and colleagues note that the optimal setting for deprescribing is not clear. The inpatient setting typically has time constraints and the inpatient physicians may be much less familiar with the whole clinical picture than the outpatient physicians. Nevertheless, an inpatient hospitalization should be considered an opportunity to consider deprescribing.
In a related commentary several Australian healthcare professionals discuss the importance of better communication channels between all parts of the healthcare system (Mitchell 2015).
While it may be time-intensive, we believe that failure to do a thorough medication review with intent to deprescribe while the patient is an inpatient is, indeed, a missed opportunity. The inpatient physicians can arrange for a time to discuss the medications with the primary care physician. The inpatient hospitalization provides another unique opportunity. We’ve mentioned on numerous occasions that physicians almost never discontinue a medication they have prescribed even if it appears on Beers’ list or the STOPP list or equivalent list of potentially inappropriate medications. But here it is possible to say “things are different now” so we are going to take you off this medication.
Some of our past columns on Beers’ List and Inappropriate
Prescribing in the Elderly:
- January 15, 2008 “Managing Dangerous Medications in the Elderly
- June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”
- October 19, 2010 “Optimizing Medications in the Elderly”
- September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
- September 2010 “Beers List and CPOE”
- June 21, 2011 “STOPP
Using Beers’ List?”
- December 2011 “Beers’
Criteria Update in the Works”
- May 7, 2013 “Drug
Errors in the Home”
- November 12, 2013 “More
on Inappropriate Meds in the Elderly”
- January 28, 2014 “Is
Polypharmacy Always Bad?”
- March 4, 2014 “Evidence-Based
Prescribing and Deprescribing in the Elderly”
- September 30, 2014 “More
on Deprescribing”
- February 10, 2015 “The
Anticholinergic Burden and Dementia”
References:
Hubbard RE, Peel NM, Scott IA, et al. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202(7): 373-377
https://www.mja.com.au/system/files/issues/202_07/hub00172.pdf
Mitchell C. Polypharmacy a shared duty. MJA InSight 2015; Monday, 20 April, 2015
https://www.mja.com.au/insight/2015/14/polypharmacy-shared-duty
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