A pilot cohort study of deprescribing for nursing home patients acutely admitted to hospital

Russell, Patrick; Laubscher, Sara; Roberts, Gregory; Mangoni, Arduino A.; McDonald, Cameron; Hendrix, Ivanka; Hewage, Udul; Hofmann, Dirk; Michell, Sophie; Taeuber, Lauren; Woodman, Richard; Shakib, Sepehr; Crawford, Gregory B.; Maddison, John; Thompson, Campbell

doi:10.1177/2042098619854876

Cited by 6 publications

(6 citation statements)

References 20 publications

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“…Albeit our sample size was relatively small ( n = 100), there was a signal of improved HRQOL, measured with Short Form-8, in those patients who had medications deprescribed. 17 As HRQOL is an important patient-centred endpoint, we addressed this issue in a larger patient population, using a different HRQOL measure, the EQ-5D-5 L, for ease of administration without loss of performance. We speculated that any improvement between 30 and 90 days post discharge would better reflect long-term medication changes made during the admission.…”

Section: Introduction/backgroundmentioning

confidence: 99%

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Russell

Hewage²,

McDonald³

et al. 2021

Therapeutic Advances in Drug Safety

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Background: Older patients from nursing homes are commonly exposed to polypharmacy before a hospital admission. Deprescribing has been promoted as a solution to this problem, though systematic reviews have not found benefit. The aim of this study was to understand if in-hospital deprescribing of certain classes of medications is associated with certain benefits or risks. Methods: We conducted a prospective, multicentre, cohort study in 239 medical inpatients ⩾75 years (mean age 87.4 years) who were exposed to polypharmacy (⩾5 medications) prior to admission and discharged to a nursing home for permanent placement. Patients were categorised by whether deprescribing occurred, mortality and readmissions were assessed 30 and 90 days after hospital discharge. The EQ-5D-5 L health survey assessed changes in health-related quality of life (HRQOL) at 90 days, with comparison to EQ-5D-5 L results at day 30. Latent class analysis (LCA) was used to investigate associations between patterns of prescribed and deprescribed medications and mortality. Results: Patients for whom deprescribing occurred had a higher Charlson Index; there were no differences between the groups in principal diagnosis, total or Beers list number of medications on admission. The number of Beers list medications increased in both groups before discharge. Patients who had medications deprescribed had nonsignificantly greater odds of dying within 90 days [odds ration (OR) = 3.23 (95% confidence interval (CI): 0.68, 14.92; p = 0.136]. Deprescribing of certain classes was associated with higher 90-day mortality: antihypertensives (OR = 2.27, 95% CI: 1.004, 5; p = 0.049) and statins (OR = 5, 95% CI: 1.61, 14.28; p = 0.005). Readmissions and 1-year mortality rates were similar. There was no deterioration in HRQOL when medications were deprescribed. LCA showed that patients with the least medication changes had the lowest mortality. Conclusion: Deprescribing certain classes of medications during hospitalisation was associated with worse mortality, but not readmissions or overall HRQOL. Larger controlled deprescribing studies targeting specific medications are warranted to further investigate these findings. This study was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN1 2616001336471. Plain language summary Background: When an older person living in a nursing home is admitted to hospital, does stopping long-term medications help them? Many older people from nursing homes take a large number of medications each day to treat symptoms and prevent adverse events. “Polypharmacy” is a term used to describe taking multiple long-term medications, and it is associated with many negative outcomes such as increased number of falls, cognitive decline, hospital readmission, even death. Deprescribing of nonessential medications – whether stopping or reducing the dose – is promoted as good hospital practice and is assumed to help older frail people live longer and feel better. However, we often don’t fully understand what is and is not essential. We wanted to better understand the effect of deprescribing long-term medications for older frail patients during an unplanned hospital admission as they were going to a nursing home to live. Methods: While admitted to hospital, medications are often reviewed by a clinical pharmacist and specialist physician. Sometimes medications are ceased; sometimes they are not. This gave us the opportunity to study two groups of older frail people from nursing homes: those who had regular, long-term medications ceased or reduced and those who did not. We wanted to see if one group did better. For example, did they feel worse if we stopped certain medications? Did they suffer other bad events compared with those patients for whom no medications were ceased? Were they readmitted to hospital earlier or more often? Results and conclusion: Despite the assumption that stopping medications for this type of patient is good practice, we found no benefit. We were also surprised to find stopping or reducing certain drug classes (e.g. antihypertensives and cholesterol-lowering drugs) was associated with greater mortality. Larger, randomised studies will better answer these important questions.

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Section: Introduction/backgroundmentioning

confidence: 99%

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Russell

Hewage²,

McDonald³

et al. 2021

Therapeutic Advances in Drug Safety

Self Cite

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“…Deprescribing has already been shown to be safe in previous reports. In their pilot cohort study (n=106), Russell et al found a significant correlation between in-hospital deprescribing and improved quality of life without any signal of harm [8]. They did not find an association with readmissions, however.…”

Section: Discussionmentioning

confidence: 90%

Deprescribing in geriatric inpatients is associated with a lower readmission risk: a case control study

Hellemans¹,

Hias²,

Walgraeve³

et al. 2020

Int J Clin Pharm

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Background: Polypharmacy is prevalent in older adults and has been associated with iatrogenic harm.Deprescribing has been promoted to reduce polypharmacy. It remains however unclear whether deprescribing during hospital stay can reduce the readmission risk.Objective: We sought to determine whether deprescribing in geriatric inpatients was associated with a lower readmission risk at three months post-discharge.Method: A case control study was performed, using data from a prospective, controlled study in geriatric inpatients. Deprescribing was defined as the percentage of discontinued preadmission medications and was assessed upon discharge. A logistic regression analysis was used to determine the odds ratio for deprescribing and the outcome of readmissions. An adjusted odds ratio was then estimated, taking into account age, sex, mortality, the number of preadmission medications and the Charlson Comorbidity Index.Results: Data of 166 patients were analysed, of whom 61 had experienced at least one readmission. Adjusting for age, number of preadmission medications and mortality resulted in the most informative regression model, based on the lowest Akaike Information Criterion (AIC) (adjusted odds ratio: 0.981, 95% confidence interval: 0.964 to 0.998). Conclusion:Deprescribing in geriatric inpatients was associated with a reduced readmission risk at three months post-discharge.

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“…This scoping review found that between 2009 and 2020, 20 studies (reported in 27 references) examined the effectiveness, safety and acceptability of deprescribing in older adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more long-term conditions) (see Appendix 3, Table 24 Material 1, Table 27; assessed effectiveness, impacts and outcomes for included studies are detailed in Report Supplementary Material 2, Table 28). [66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85] Of the 662 studies excluded at full-text stage, 148 were not explicit in stating or did not meet the number of multimorbidities [i.e. did not define their population as multimorbid (two or more long-term conditions), or reported mean/medians] and did not define or meet polypharmacy as being five or more drugs, 99 studies met the polypharmacy criteria (five or more prescribed medications) but did not meet/state the number of multimorbidities as two or more long-term conditions and 26 met the multimorbidity criteria but did not meet or define the polypharmacy criteria (see Report Supplementary Material 3, Table 29).…”

Section: Search and Screening Resultsmentioning

confidence: 99%

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

Reeve

Maden

Hill

et al. 2022

Health Technol Assess

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Background Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. Objectives We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes ‘best practice’ and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. Data sources Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). Review methods The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. Results Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context–mechanism–outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. Limitations Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. Conclusions Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. Future work The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. Study registration This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

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A pilot cohort study of deprescribing for nursing home patients acutely admitted to hospital

Cited by 6 publications

References 20 publications

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Deprescribing in geriatric inpatients is associated with a lower readmission risk: a case control study

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

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