Lessons for Deprescribing From a Nonessential Medication Hold Policy in US Nursing Homes

Kevin W. McConeghy Pharm.D; Michael Cinque Pharm.D; Elizabeth M. White APRN, PhD; Richard A. Feifer MD, MPH; Carolyn Blackman MD; Vincent Mor PhD; Stefan Gravenstein MD, MPH; Andrew R. Zullo Pharm.D, PhD

Disclosures

J Am Geriatr Soc. 2022;70(2):429-438. 

In This Article

Abstract and Introduction

Abstract

Background: At the height of the COVID-19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. We describe rates of held and discontinued medications after a temporary hold policy of potentially unnecessary or nonessential medications.

Methods: This retrospective cohort study uses electronic health record (EHR) data on 3247 residents of 64 nursing homes operated by a multistate long-term care provider. Medications were documented in the electronic medication administration record. Overall medication held and discontinued incidences are reported. Hierarchical Bayesian modeling is used to determine individual probabilities for medication discontinuation within each facility.

Results: In total, 3247 residents had 5297 nonessential medications held. Multivitamins were most likely to be held, followed by histamine-2 receptor antagonists, antihistamines, and statins. At the end of the hold policy, 2897 of 5297 (54%) were permanently discontinued, including probiotics (73%), histamine-2 receptor antagonists (66%), antihistamines (64%), and statins (45%). Demographics, cognitive and functional impairment were similar between residents with medications who were discontinued versus continued. For most medications, more than 50% of the variance in whether medications were discontinued was explained by facility rather than resident-level factors.

Conclusion: A temporary medication hold policy implemented during the CoVID-19 pandemic led to the deprescribing of a plurality of 'nonessential' medications. This type of organization-wide initiative may be an effective mechanism for altering future prescribing behaviors to reduce the use of unnecessary medications.

Introduction

In the early months of the COVID-19 pandemic, nursing homes had to adjust rapidly to multiple new care processes to manage a respiratory virus that spreads without symptoms and had devastating effects on both residents and staff. These included the implementation of new quarantine and isolation practices, procurement, and use of personal protective equipment (PPE); daily symptom and exposure screens for staff and residents; adaptation of complex testing protocols; and clinical management of acutely ill residents.[1] All of this occurred while nursing homes nationwide were facing staffing shortages due to staff illness and quarantine, disruption of supply chains for PPE and testing supplies, and a health system in crisis.[2,3]

To conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact, national long-term care experts proposed crisis standards of care.[4,5] Many vitamins, nutritional supplements (e.g., iron supplements), and stool softeners (e.g., docusate) provide minimal clinical benefit unless specific deficiencies are present or symptomatic relief is achieved.[5] Included in these proposals were recommendations to review medication regimens to identify medications that were of minimal clinical benefit and that could be either temporarily held or permanently discontinued. One such policy was the "nonessential medication on hold" (NEMOH) policy that was implemented by a large multistate long-term care provider.

The NEMOH policy was activated during a COVID-19 outbreak, and nonessential medications were placed on a hold for a period of time, then providers could choose to restart or discontinue them. Although not its original purpose, this made NEMOH an ad hoc deprescribing initiative.

Deprescribing is generally defined as the clinically supervised process of stopping or reducing the dose of medications that no longer provide benefits that outweigh potential risks.[6,7] The goals of deprescribing are to reduce the risk of adverse drug events, improve quality of life, and optimize the outcomes that matter most to residents and their families.[7–10] Deprescribing is an important tenet of geriatrics aimed at reducing polypharmacy, i.e., the regular use of five or medications, and is particularly important for nursing home residents who commonly take nine or more medications.[11] However, there is limited translation of deprescribing into clinical practice for older nursing home residents. To date, nearly all deprescribing initiatives and interventions have been resident-centric and intensely focused on shared decision-making.[10,12] Little is known about how to design and implement system-level interventions at a scale necessary to produce a meaningful impact without compromising residents' and caregivers' individual needs and preferences. The medication hold policies implemented during the pandemic offer a unique opportunity to understand how system-level deprescribing interventions might be optimally designed.

Therefore, we (1) report held proportions of medications eligible under the NEMOH policy, (2) measure the proportion of those held medications, which were subsequently discontinued, and (3) identify facility- and resident-level factors that were predictive of restarting held medications.

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