The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care

Emily G. McDonald, MD, MSc; Peter E. Wu, MD, MSc; Babak Rashidi, MD, MHI; Alan J. Forster, MD, MSc; Allen Huang, MDCM; Louise Pilote, MD, PhD; Louise Papillon-Ferland, BPharm, MSc; André Bonnici, BPharm; Robyn Tamblyn, PhD; Rachel Whitty, BScPhm; Sandra Porter, BPharm; Kiran Battu, BPharm; James Downar, MD; Todd C. Lee, MD, MPH

Disclosures

J Am Geriatr Soc. 2019;67(9):1843-1850. 

In This Article

Abstract and Introduction

Abstract

Objectives: Polypharmacy is common, costly, and harmful for hospitalized older adults. Scalable strategies to reduce the burden of potentially inappropriate medications (PIMs) are needed. We sought to leverage medication reconciliation in hospitalized older adults by pairing with MedSafer, an electronic decision support tool for deprescribing.

Design: This was a nonrandomized controlled before-and-after study.

Setting: The study took place on four internal medicine clinical teaching units.

Participants: Subjects were aged 65 years and older, had an expected prognosis of 3 or more months, and were taking five or more usual home medications.

Intervention: In the baseline phase, patients received usual care that was medication reconciliation. Patients in the intervention arm also had a "deprescribing opportunity report" generated by MedSafer and provided to their in-hospital treating team.

Measurements: The primary outcome was ascertained at the time of hospital discharge and was the proportion of patients who had one or more PIMs deprescribed.

Results: A total of 1066 patients were enrolled, and deprescribing opportunities were present for 873 (82%; 418 during the control and 455 during the intervention phases, respectively). The proportion of patients with one or more PIMs deprescribed at discharge increased from 46.9% in the control period to 54.7% in the intervention period with an adjusted absolute risk difference of 8.3% (2.9%-13.9%). Not all classes of drugs in the intervention arm were associated with an increase in deprescribing, and new PIM starts were equally common in both arms of the study.

Conclusion: Using an electronic decision support tool for deprescribing, we increased the proportion of patients with one or more PIMs deprescribed at hospital discharge as compared with usual care. Although this type of intervention may help address medication overload in hospitalized patients, it also underscores the importance of powering future trials for a reduction in adverse drug events.

Introduction

Polypharmacy, or the concurrent use of multiple medications, is common, costly, and harmful.[1–3] As many as 40% of community-dwelling older adults are regularly prescribed five or more medications, despite being a population that is particularly vulnerable to adverse drug events (ADEs).[4–6] Although several consensus-derived lists of potentially inappropriate medications (PIMs) for older adults[7–10] exist that can be used as reference guides for comprehensive medication reviews, these lists can be challenging to translate into everyday practice. Lists of PIMs may not be applicable on an individual patient level[11] and the process of cross-referencing multiple medications and medical conditions for the large number of patients who could benefit requires a command of the literature and is time consuming. Previously described strategies to address polypharmacy have demonstrated variable efficacy,[12–16] with interventions led by pharmacists having the greatest success. Nevertheless, interventions can be limited by cost, time constraints, and the need for expert personnel who may be in short supply.[17–19]

In this study (NCT02918058), we tested MedSafer, a Canadian-made electronic decision support tool for deprescribing (www.medsafer.org). We used the tool to facilitate deprescribing in acute care for the following reasons: polypharmacy is common in this population where the average number of drugs can exceed 10;[20] hospitalization provides a unique point of contact with the healthcare system and can involve specialists with familiarity in managing polypharmacy; electronic decision support for reducing PIMs has shown promise in the acute care setting;[21] and finally, there is a unique opportunity to engage patients and/or families in deprescribing because they may be both a "captive audience" and motivated to stop medications that may have contributed to the hospitalization.[22] Using an electronic decision support tool that identified PIMs and generated "deprescribing opportunity reports" for the treating teams, we aimed to increase the proportion of patients with one or more PIMs deprescribed at hospital discharge and overcome barriers to deprescribing in acute care.

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