A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records

Abstract

Aims The drug burden index (DBI) measures a person's total exposure to anticholinergic and sedative medications, which are commonly associated with harm. Through incorporating the DBI in electronic medical records (eMR) and implementing a DBI stewardship program, we aimed to determine (i) uptake of the steward's recommendations to deprescribe anticholinergic and/or sedative drugs by the medical team and (ii) whether accepted recommendations were actioned in hospital or recommended for follow‐up by the General Practitioner post‐discharge. Methods A single‐arm, non‐randomised feasibility study was performed at an Australian tertiary referral metropolitan hospital. The stewardship pharmacist reviewed eMRs of patients aged ≥75 years with DBI scores > 0, during admission. The steward identified and discussed potential opportunities to deprescribe anticholinergic and/or sedative medications with the medical registrars. Results Amongst 256 patients reviewed, the steward made 170 recommendations for 117 patients. Registrars agreed with 141 recommendations (82.9%) for 95 patients (81.2%), and actioned 115 deprescribing recommendations for 80 patients, most commonly for antidepressants and opioids. The 115 actioned recommendations resulted in 125 changes, with 44 changes to the inpatient drug chart and 81 additional changes recommended post‐discharge in the discharge summary. Conclusion Opportunities exist for deprescribing anticholinergic and sedative medications in older inpatients and a DBI stewardship program may help implement these. It is important to capture different outcomes of deprescribing interventions, including in‐hospital medication changes, recommendations in the Discharge Summary, sustainability of deprescribing and clinical outcomes.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

“…Secondly, the recommendations are detailed in the discharge summary, which allows fluid communication with other levels of care. Both strategies have been shown in previous studies to be facilitators for de-prescription [ 55 ].…”

“…In addition, we performed the MR according to the administered medication when patients were recruited and, at the 3 month follow-up, we verified the persistence of the proposed changes in the electronic prescription without analyzing the medication compliance in both situations. Finally, to facilitate daily practice, the use of electronic systems that automatically calculate the DBI and the frailty index would be very useful [ 55 ].…”

Polypharmacy Is Associated with Sociodemographic Factors and Socioeconomic Status in United States Adults

“…A multifaceted intervention targeting medication safety as a workable solution to public health issues could benefit from the novel idea of polypharmacy stewardship, which aims to minimize medication-related harm and promote appropriate medication use in older adults [ 68 ]. The potential benefits of polypharmacy stewardship in older patients with multimorbidity in a hospital context were demonstrated effectively by an open-label non-randomized feasibility trial conducted in Australia in 2023 [ 69 ]. Therefore, it is advisable to consider the application of polypharmacy stewardship in a range of healthcare environments.…”

Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study

“…The stewardship process involved the following steps: (1) identifying patients with a DBI > 0 using the pharmacy patient list, (2) undertaking a medication review for eligible patients using patient’s medical conditions, medications prior to hospitalisation and medications in hospital, any drug allergies or intolerances, reason for visit, progress prior to stewardship review and any investigations, (3) creating a list of potential deprescribing opportunities for eligible patients, and (4) discussing deprescribing opportunities with the medical registrar, such as recommending deprescribing opportunities, asking for reasons for rejection of any recommendations, and promoting the use of deprescribing guides and consumer information leaflets to aid deprescribing. Detailed description of the stewardship program and the uptake of deprescribing recommendations were reported previously [ 23 ]. Detailed example of how the stewardship process was applied to a hypothetical patient is shown in Appendix 3.…”

“…Given that deprescribing is a complex intervention, a multifaceted intervention bundle including deprescribing guides, consumer information leaflets and education materials on polypharmacy in older inpatients may help clinicians to facilitate implementation of a CDSS in clinical practice. We hypothesised that the DBI calculator integrated into the eMR with accompanying resources and a stewardship program could help identify and act on opportunities for deprescribing in older inpatients [ 22 , 23 ]. The objectives of this study were to investigate the impact of the comprehensive intervention bundle using the DBI on (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge compared with hospital admission and (ii) deprescribing of different DBI-contributing medication classes during hospitalisation.…”