Recently the Canadian Journal of Hospital Pharmacy (CJHP) published an article where the question “Should hospital admission be used as an opportunity for deprescribing in older adults?” was fiercely debated.
Today we interview two hospital pharmacists, Pam Howell (GeriMedRisk, Ontario, Canada) and Lisa Richardson (Saint-Vincent Hospital and Bruyère Deprescribing Research Team, Ontario, Canada) to get their thoughts on this question.
Pam Howell Lisa Richardson
Q: What were your initial thoughts when you read this article?
Pam and Lisa: The authors presented a very thought-provoking case for the ‘pros’ and ‘cons’ of deprescribing during a hospital admission. There is no doubt that opportunities exist. Access to what is described as a “controlled” environment definitely sets the stage for success. It allows for a collaborative approach between the team and patient with close monitoring during the process. On the other hand, the ‘cons’ side challenged the role for hospitalists to deprescribe, quoting a lack of time, low priority in the face of acute medical issues, and risks to continuity of care with the community providers.
The ‘cons’ side of this article really struck a chord with us. Though we agree challenges exist, it doesn’t mean that hospitalists should shy away from deprescribing or think their community colleagues are better equipped. Our work with the Bruyère Deprescribing Research Team has made us appreciate that clinicians face the same barriers across all healthcare settings – whether it is the confidence to make changes, lack of time, or patient uneasiness. Addressing medication harms is a priority for every clinician, no matter what practice setting, and is part of optimizing a person’s health. Successful deprescribing is possible in hospital settings because we practice it every day with every one of our patients. Our medication reviews not only look at starting medications, but also the need for stopping or lowering doses.
Q: The ‘cons’ side of the article argues lack of follow-up and continuity of care as a reason against deprescribing in-hospital. What do you think about that?
Pam and Lisa: It is true that transitions of care have been shown to increase the risk for medication-related harm. It is why programs such as medication reconciliation are so important at admission and discharge. Medications are consistently started in-hospital, requiring monitoring and follow-up after discharge. If medications can be started, why can’t they be stopped? Especially if they contributed to the reason for admission in the first place. The key is communicating properly with community colleagues. When new medications are started in-hospital, patients are generally discharged with a prescription for that medication. ‘Prescriptions’ to stop medications should also be written. This helps alert everyone, including the community pharmacist, to the intended changes. Discharge summaries should also include details on any medications that may have been stopped and why. If a drug is started, documenting the reason for use is a must. All of these pieces help continuity.
None of these pieces is impossible to implement. At Bruyѐre Continuing Care, we often reach out to the primary care provider or specialist when things are not clear or if we are looking for input. Based on best practices, our electronic discharge prescriptions have evolved to include space for the doctor and pharmacist to document the rationale for drug changes plus any follow-up suggested. A pharmacist’s contact name and number are also included in case of questions or concerns.
Q: What has been your experience with using admission to hospital as an opportunity for deprescribing?
Pam: My role as the medication expert is highly supported and the team approach is pivotal to implementing a successful medication plan. It is very rare that I am not promoting deprescribing and staff are quick to help point out opportunities or monitor the effects of any changes. The most impactful experience was seeing the physical and mental improvements in a patient that came in taking 56 pills per day that we deprescribed to 26. He was no longer confused and he thanked me profusely as he left saying, “You have nothing without your mind”. He is the reason I chose to be an active part of the deprescribing movement.
Lisa: Part of my role as a hospital pharmacist involves creating medication care plans, which more often than not includes opportunities for potential deprescribing. When looking at a patient’s medication list, I look to see if there is an ongoing indication for each medication. I also look to see if the medication is providing benefit to the patient or if it may be causing side effects. Whenever considering deprescribing, I think it is also extremely important to involve the patient. I would encourage you to look to your patients for information. Shared decision-making is an integral part of deprescribing. Patients can share knowledge about their medication goals and experiences that is important in guiding any decision about deprescribing. Like Pam mentioned, using a team approach is also so important for helping monitor the effects of any changes made. I have found deprescribing in this setting not only feasible but beneficial for patient care.
Q: Any last thoughts?
Pam and Lisa: There is no “ideal” setting for deprescribing and waiting for such a thing is exactly why polypharmacy has existed for decades. Deprescribing interventions can be big or small and success is founded on evidence-based recommendations, patient engagement, and effective communication with community partners. Even if changes are not done on admission, presenting even the possibility of deprescribing to the patient may be just what is needed to start the ball rolling in the future. Perhaps the issue should not be discussed in terms of pros and cons, but instead how to promote better medication practices within the continuum of the patient’s health journey. That holistic care involves both appropriate prescribing and deprescribing.