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A year ago we did our first “Deprescribing Super Special”.  Today we are coming back for more (or less given the content), talking about the following articles with their lead authors:

First up, we talk with Ariel Green about her article in JAMA Network on preferred phrases a clinician may use to explain why they should reduce or stop the medication.   My take home from this is that while the most preferred explanation for deprescribing statins and sedative-hypnotics is one focused on the risk of side effects, we also need to individualize it to the patient and the medication that they are taking.

Next up, we chat with Liz Bayliss about her JAMA IM article that studied whether increasing awareness about deprescribing prior to primary care visits can reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment.  While the study was largely negative, it does bring up important implications about how we should think about deprescribing in older adults (added bonus too – all of the resources used in the study can be found on the US Deprescribing Research Network website).

Lastly, we talk with Kevin McConeghy about one deprescribing intervention that was hugely successful, although somewhat atypical.  Kevin’s study looks at a period of time in the COVID pandemic when a large multistate nursing home provider created a “nonessential medication on hold” (NEMOH) policy in order to conserve critical nursing resources and PPE, and to limit exposure risk for residents by reducing unnecessary contact.  Although the policy was not originally envisioned as a deprescribing intervention, 54% of held medications were discontinued.  That’s huge!  While it’s unlikely this will be repeated, we talk about lessons we can learn from this natural experiment.  

Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we are delighted to welcome a wonderful group to talk about deprescribing. Liz Bayliss is Senior Investigator at Kaiser Permanente Colorado Institute for Health Research, and Professor of Family Medicine at the University of Colorado. Welcome, Liz, to the GeriPal Podcast.

Elizabeth: Nice to be here.

Alex: And we have Ariel Green, who’s a geriatrician and Associate Professor of Medicine at Johns Hopkins. Welcome, Ariel.

Ariel: Thanks. I’m excited to be here.

Alex: And we have Kevin McConeghy, who is a clinical pharmacy specialist at the VA Medical Center in Providence, and a PhD candidate at the Brown School of Public Health. Welcome to the GeriPal Podcast, Kevin.

Kevin: Thank you. Great to be here.

Eric: So we’re calling this a deprescribing super special. We’ve done some deprescribing episodes before, but never a super special. Right, Alex?

Alex: No, I think we did one other super special.

Alex: So this is Super special 2. Yeah.

Eric: Before we jump into the topic, we’ve got some great papers to review. One in JAMA Network. One in, was it JAMA IM? Another in JAG. But before we do that, somebody have a song request for Alex?

Kevin: I believe I have a song request for Pills by St. Vincent.

Alex: Normally we ask you why you chose this song, but this one will be obvious. There’s no real need for an explanation. So obviously this is, for those of you who know the song, not at all an acoustic guitar song. So we’ll see what happens here.

Alex: (singing)

Eric: We’ll get a little bit more of that song at the end of the podcast.

Kevin: That was awesome.

Ariel: That was amazing.

Eric: Okay. So let’s jump right into this. For the folks who haven’t listened to our past podcast, I really just want to start off with maybe two quicker answers.

Eric: What the heck is deprescribing? Because we bring it up a lot. Is there a formal definition, or one that you think about? And why is it important when we’re caring for older adults or those with serious illness? Ariel, you want to take that question?

Ariel: Sure. So deprescribing is a planned and intentional process of dose reduction or stopping a medicine that is potentially harmful to an individual, for which the harms are more likely to outweigh the benefits, or that is no longer aligned with that person’s goals.

Eric: If somebody just stops medicine at home or just no longer takes it because they’re forgetting, that’s not deprescribing. If it falls off their med list and we forget to renew it, not deprescribing. Has to be intentional, has to be planned, and it’s a process.

Ariel: Yes. I would say that’s true. If somebody stops taking a medicine at home and then talks with their clinician about it and they decide that that makes more sense to them, then that would be deprescribing. But right, if they stop taking it for another reason, or it falls off the list, that would not be deprescribing.

Eric: I’m thinking back to my own medical training; there was a lot of focus on how to talk to patients about starting new medications, the benefits … I don’t want to say, how to convince patients. But how to talk to patients about the risk and benefits when starting. What do we know, if you can briefly summarize, why is deprescribing important?

Ariel: I think that, as you pointed out, we have a lot of evidence and a lot of research about when it’s helpful to start medicines, what the benefits are of medicines; but a lot less about when we should consider stopping medicines, and when the harms may outweigh the benefits.

Ariel: As we all know, as geriatricians in geriatrics research, people accumulate conditions and accumulate medicines over the years. And as we’ve all witnessed, it gets to a point where things are just unmanageable. People are taking things that no longer make sense for them in the context of their overall health.

Ariel: So deprescribing is important because we frequently encounter situations where the benefits of medicines may be outweighed by the potential harms. Deprescribing helps us help patients navigate that.

Eric: Yeah. So you had a paper published in JAMA Network Open not too … was it last year?

Ariel: I think so.

Eric: Think it was ’21. Yeah, April 5th, 2021. About, was it how to talk to patients? Or phrases? Tell me about your JAMA Network Open paper.

Ariel: This was really designed with the clinician in mind. We wanted to give clinicians phrases that they could keep in their back pocket and use when discussing deprescribing with patients and caregivers. And this paper really gave us some important insights into older adults’ priorities about medication use that can inform these conversations.

Ariel: Our goal was to gain a deeper understanding of key phrases that we can use to frame conversations about deprescribing in language that resonates with older adults. We used a large online survey panel, the Ipsos Knowledge Panel, and we presented older adults with two vignettes.

Ariel: One described an older adult with multiple comorbidities and functional impairment, who was taking a statin for primary prevention. The other described a healthy older adult with good functional status who was taking Zolpidem for insomnia.

Ariel: We designed the vignettes to look at a preventive medicine and a symptom relief medicine. And after each vignette, we presented seven rationales that a trusted clinician could use to explain why the person should stop taking that medicine.

Eric: When you say “rationale,” those are phrases, like for statins: “The benefit of this medicine do not clearly outweigh the risk for people like you.”

Ariel: Exactly. And these phrases or rationales came from our clinical experience as geriatricians, as well as from qualitative research that we had done with older adults, and with caregivers and clinicians.

Ariel: Then we used a method for assessing individuals’ priorities called best-worst scaling, in which respondents are shown various combinations of the items; in this case, the phrases or rationales; and asked to choose the best and worst item from each set. Would you like me to tell you [inaudible 00:08:17]-

Eric: Yeah, I’m eager. What did they like? Or what did they not like?

Ariel: For both medication classes, the preventive medicine and the symptom relief medicine, they liked the same thing. They liked the phrase that focused on the risk of side effects.

Ariel: For preventive medicines, for the statin, they also liked phrases that included references to using a harmful total number of medicines, and to the benefits not outweighing the risks.

Ariel: Then for Zolpidem, the symptom relief medicine, other phrases that they liked included a reference to the patient and clinician working together to gradually reduce the dose and taper them off of it over time, and the phrase about the medicine causing more harm than good.

Ariel: Then would you like me to tell you about the phrases they did not like?

Eric: Yes!

Alex: Mm-hmm.

Ariel: Okay. The least preferred phrase for statins, surprisingly to us, focused on the effort or treatment burden involved in taking the medicine. We had a phrase about taking this medicine as an additional pill for you to swallow, and requires periodic lab tests for monitoring and…

Eric: And cost you money.

Ariel: Yes. And costs you money. Right. And the least-preferred phrase for Zolpidem was the phrase, also surprising to us, that said, “This medicine is unlikely to help you function better.”

Eric: Huh.

Alex: Huh.

Eric: Ariel, you’re a geriatrician, right?

Ariel: Yes.

Eric: Did these results change at all how you talk to patients about deprescribing?

Ariel: They did in the sense that I am more likely now to focus on risk of side effects. Well, I think first of all, the results reminded me of the importance of really getting to know the patient first, and not assuming that everyone has the same preferences.

Ariel: We also found that there was a lot of variability. Even phrases that were the most preferred, were least preferred by some. Also, as geriatricians, I think we tend to … or I had assumed that, or I’d always believed that avoiding treatment burden was really important.

Ariel: But at least to the respondents … and I think it still is for a lot of people, and potentially for people who have more comorbidities or more medicines … but at least to the people who responded to this online survey, the results showed that many of them were willing to go through what I would consider burden to take a medicine that could potentially prevent bad things from happening down the road. That was surprising to me.

Ariel: Also the phrase for Zolpidem about the medicine being unlikely to help you function better. When talking to people about potentially inappropriate medicines like Zolpidem, I used to say a phrase like that. And at least for the people who responded to this, I think if they didn’t see themselves as having functional impairments, so they didn’t see why it would matter that it won’t help them moving forward.

Alex: What about for statins? When you’re talking about side effects, which side effects were highlighted there?

Ariel: We talked about things like potential interactions with other medicines, potential muscle weakness, and some GI side effects.

Alex: Mm-hmm.

Eric: I think it’s hard for a lot of people who’ve been taking statins or benzos for a while. They may not feel like they’re having side effects; they’re tolerating well. Maybe that’s where the individualizing it, the person that’s front of me.

Eric: Maybe it’s not about … unless, like, for benzos, you can talk about the cognitive aspects, or if they’re having falls, the side effect there. But for statins, maybe focusing more on the benefits, not having harms or the harmful number of medications. So maybe individualized; is that right?

Ariel: Yeah. I think that is a good takeaway from this.

Alex: So you have to individualize the patient in front of you, and to the medicine, and to the circumstance in which they’re in. So somebody’s been taking it for a long time will have a different perspective from somebody who just started the medicine.

Ariel: Yeah. I think that is true. And I think for the potentially inappropriate medicines, it also highlighted to me the importance of really linking: understanding what their goals are. Things like avoiding cognitive impairment or avoiding falls.

Ariel: Or potentially, as you mentioned, people may have actually had already an ED visit for a fall, and no one ever made that link for them between the fact that they’re taking a medicine that’s associated with increased risk of those things. And they may have already had a fall.

Eric: So an educational component potentially going on there. Now which brings us to Liz’s paper in JAMA IM on the optimized pragmatic cluster, randomized controlled trial published March 28th, 2022 about a deprescribing education versus usual care for patients with cognitive impairment and primary care clinicians. Liz, why’d you decide to do this?

Elizabeth: Well, I decided to do it because as Ariel’s just pointed out, deprescribing is important. It’s underappreciated, I think, by providers and by patients. The potential benefits are not well known.

Elizabeth: And the optimized trial, first of all, it focused on a population that has the potential to, we think, really benefit from deprescribing, which is older adults with cognitive impairment.

Elizabeth: So people who either had dementia or mild cognitive impairment who are at particular risk for side effects, especially cognitive side effects from certain medications that they might be able to discontinue. That was the target group.

Elizabeth: And speaking of education, the trials sought to educate patients and any caregivers that were helping those patients, as well as clinicians in a pragmatic trial design, in which we identified people in half of the Kaiser Colorado primary care clinics who met our criteria, sent them brochures that educated them about the potential to consider stopping unnecessary medications, and encourage them to talk to their provider at their upcoming visit.

Elizabeth: Then at the same time, over the course of a year, we provided what we call tip sheets, which were educational nuggets for clinicians once a month at their provider meetings. Ariel’s on the optimized team, and her work on how to help clinicians talk to patients about deprescribing informed the content of those tip sheets, which was great.

Elizabeth: Because when we talked to the providers about the deprescribing project, they all said, “Yeah, we know this is important. You don’t need to tell us this is important. But there are certain situations that we encounter where we don’t actually know how to begin the conversation, or we don’t know how to have the conversation in the opportunities that are presented to us.”

Elizabeth: So the idea behind optimize was what if we prepare the patient? It’s kind of the chronic care model, right? You prepare the patient to have the discussion, and to be aware of the potential to consider stopping medications. Then you prepare the provider to have the discussion also.

Elizabeth: And because it was a pragmatic design, it was actually quite hands off. We weren’t doing any medication management from a research standpoint; we were providing the information to these two groups of people.

Eric: Can I ask?

Elizabeth: Yeah.

Eric: So, two components: you got a patient focused, sounds like component and a provider. The patient, you start off by sending them a booklet. Was it targeted to what medicines they’re on? Or was it just a general deprescribing booklet?

Elizabeth: It was general deprescribing, because we weren’t targeting certain medications. We were targeting people who were taking five or more chronic medications.

Elizabeth: The little brochure, which was one of those little trifold brochures; it wasn’t a lot to read; presented the idea of talking to your provider about whether you could safely take fewer medicines. So it was not focused on the single drug.

Eric: And the second question: you’re sending this to people who all had either Alzheimer’s disease or related dementias or MCI. I can imagine also sending educational booklets to those people with cognitive issues also may bring up some thoughts of, “Is this really going to work?” What did you think? How did you think through that when you were putting this study together?

Elizabeth: You mean in terms of whether or not providing these materials would be absorbed and used by the target population?

Eric: Yeah.

Elizabeth: We targeted people at a whole range of potential cognitive impairment, from very little to potentially more. They were all community dwelling; this wasn’t focused on people who were in skilled nursing facilities or dementia care units or those sorts of settings. So people could live in the community.

Elizabeth: Then we had in the pragmatic way of design of the study, we had to assume that people who had caregivers who were integral to their mail management and their medical care were likely to open the mail that came from their medical provider, so that the caregivers would also read the brochure.

Eric: Yeah. And then for the provider standpoint, what information did you provide them?

Elizabeth: Each month they got what we called a tip sheet over the course of the whole year. So 11 of them. They were really designed to be soundbites, basically, of information. One of them might be titled Introducing Deprescribing to Patients.

Elizabeth: And each of these tip sheets provided some quotes that providers might use, or things they could try. For example, when you prescribe a medication, mention that most people won’t need that medication forever. Or on a different topic, there was another topic on Deprescribing to Improve Troubling Symptoms, getting back to Ariel’s learnings.

Elizabeth: We provided the providers with the phrases like, “The symptom you’re describing may actually be due to your such-and-such medicine.” So feeding them little soundbites that they might be able to take off the tip sheet and use if they had the opportunity.

Eric: Now, that’s fabulous. Are those tip sheets available anywhere or is it just …

Elizabeth: They are all available. The brochure is available that we developed, the trifold brochure and the tip sheets are all available. They’re on the US Deprescribing Research Network website.

Eric: Great!

Elizabeth: And they can be downloaded and adapted and used. They’ve got a Creative Commons license. People can [inaudible 00:20:24] with them for their own needs.

Eric: Fabulous. We’ll have links to that on this GeriPal Podcast notes.

Eric: All right, Liz. Now I got to ask a question: did it do anything?

Elizabeth: Well … sort of, maybe. Not really. It was essentially a negative study in terms of comparing the outcomes at six months of total number of chronic medications, and proportion of individuals taking one or more potentially inappropriate medications. Those were our two main outcomes.

Elizabeth: Looking at the group of people in control clinics versus intervention clinics: on those two outcomes, there was no difference in those two outcomes for the group taking five or more medications.

Elizabeth: I will say that if we hone down the enrollment criteria, the number of medications, and looked at people who were taking seven or more as compared to five or more medications, it did look to us like for the people taking seven or more medications, they were significantly more likely to be taking fewer potentially inappropriate meds at the end of the study.

Elizabeth: We’re not really hanging our hat on that. I think it’s a lot to ask of this study to really call that a major finding. But we think that it did suggest to us that people who are taking more medications at baseline, may be in a much better position to potentially back off.

Eric: And how many of these folks were actually taking potentially inappropriate … Wait, what is a potentially inappropriate medication?

Elizabeth: Well, we used an adaptation of the Beers List to create a list of potentially inappropriate meds. It was not a full reincarnation of the Beers List, but it highlighted those especially risky for people with cognitive impairment. Then we also added opioid medications to that as potential target meds for deprescribing.

Eric: Yeah. And it’s, importantly, potentially inappropriate. Not saying it’s inappropriate.

Elizabeth: Not saying. For deprescribing, I think of potentially inappropriate medications as kind of broad, right? Because we’re talking about what Ariel defined earlier, which is, would this be a medication that could be inconsistent with somebody’s goals of care, and that a provider might consider stopping? It’s not an objective good/bad kind of thing. It’s more of a, could this be a target medication for discontinuation?

Eric: Looking like it’s high risk antidepressants; things like nortriptyline, TCAs, antihistamines, antimuscarinics, antispasmodics, antispsychotics, benzos, H2 receptor antagonists like Ranitidine-

Elizabeth: PPIs.

Eric: … PPIs. So did it have an effect? Wait, how many of those folks were actually getting potentially inappropriate medications?

Elizabeth: At the start?

Eric: Yeah.

Elizabeth: We actually didn’t count the potentially inappropriate meds. We counted the proportion of people taking one or more. At the beginning, let’s see, we had 30% in both the intervention and the control groups who were taking one or more potentially inappropriate medication at baseline.

Alex: Hmm.

Elizabeth: So not a ton, but not zero by any means.

Alex: Right.

Eric: Right. Do you think the people who are taking more than seven medicines or higher medicines, they probably had a higher rate of potentially inappropriate medications-

Alex: Sure.

Elizabeth: Yeah. I would think so.

Alex: Yeah. The more meds you take, the greater likelihood that you’re going to take a potentially inappropriate medication.

Alex: Liz, what about adherence or uptake of the brochure? Do you know if anybody read it, or if the clinicians read the 11 prompts?

Elizabeth: We did some debriefing interviews with both patients and providers. I will say that we stopped the trial in March of 2020, which was when COVID started. So our follow up was impacted a little bit by all the care changes associated with the pandemic. When we call people and say, “Do you remember that brochure from January?” their minds have been elsewhere in terms of healthcare delivery.

Elizabeth: But we did find that people did like the brochure. They remembered getting it. We talked to caregivers and patients; it was well accepted. Some people didn’t remember it and others did.

Elizabeth: The providers quite liked the tip sheets. The providers live in … You guys know this … everybody lives in the real world. People know it’s important. They like the tip sheets. They appreciated the content. And it’s still hard to find time in an office visit to have the discussion about deprescribing.

Alex: Huh. Ariel and Kevin, were either of you surprised that this intervention kind of didn’t work?

Ariel: I mean, I think, as Liz mentioned, it was very pragmatic and very low touch. So I think what we talked a lot about on the optimized team was if we could change the culture of medicine and of prescribing, rather, so that we are more thoughtful about whether to start medicines or whether to continue medicines; that would be the goal. But I think that takes a long time, and may take a little bit more of a touch than what this did.

Alex: Yeah. It seems to me that when a clinician is starting a med, they almost are pitching it to patients. They overemphasize the benefits and they don’t go into the harms as much, or they minimize them.

Alex: As you said earlier, they don’t say that, “This medicine may not be something you take for the rest of your life. It may be something that’s we try for a while, and there will come a time when we’ll stop it.”

Alex: Kevin, how about you? Were you surprised by this?

Kevin: Yeah. There’s been a number of investigators at Brown over the last five, 10 years who have done pragmatic trials in the nursing home setting, and have really struggled to show an impact from whatever intervention they were trying to pilot, whether it was any microbial stewardship or the Prueba trial, like different music and memory interventions.

Kevin: People believe really passionately. These things do matter, they hope. We have some evidence to suggest they help; but when we actually try to show a difference in outcomes, it has been a real challenge.

Kevin: So I’ve become a little pessimistic in any pragmatic trial to show a difference in outcomes. But at the same time, there isn’t really another option except to try to refine them and pursue them. And …

Eric: Well, I mean, culture change is hard.

Kevin: Yeah. For example-

Eric: Changing people for providers’ practices is hard. Why don’t you just take them out of the equation and just create a system that removes non-essential medications?

Elizabeth: Think about our systems. They’re all designed to make refills easier, right? And often populated with multiple months of automatic refills for things like PPIs. So there is the potential for system change, I think.

Eric: Well, I’m going to bring up Kevin’s JAGS article on deprescribing from a non-essential medication hold policy in the U.S. nursing homes. Kevin, how’d you think about, even thinking about looking at what happened here? Well, how about this? Tell us what happened here that you looked at.

Kevin: You know, if I can give a little plug for your previous podcast. I think actually the last episode you did, talking about the early phase of the pandemic, gives some great context to what was happening, and what we’re describing in this paper.

Kevin: So juxtapose everything that was just discussed in terms of highly purposeful, well-thought experiments and qualitative research to try to understand how to communicate things. This is more at the height of a very unusual and stressful time for nursing homes, at a point where staff residents were really desperate for some help, because they were so overburdened by care and the unusual infection control procedures and the lockdowns.

Kevin: A policy was put in place that they referred to as the NEMO Policy, or the acronym for Non-Essential Medication on Hold. The policy was informed by some guidelines that gave a logical explanation for what medications might be potentially unnecessary for care, particularly in an emergency situation. And the medication list was agreed on by the nursing home operator and the medical center directors.

Kevin: Then the idea was that if a nursing home had an outbreak of COVID, they would enact the medication on hold policy. And the medical center director working with the local providers would put medications that were part of this list on hold: which meant they weren’t discontinued, but they weren’t being administered.

Kevin: It was essentially what I would describe as an opt-out policy. If the provider or the resident felt really strongly that the medication needed to be continued, that it would be. But if there was no objection, it would be placed on hold.

Kevin: And it turns out if you institute that policy in that kind of a setting, about 50% of all the medications that could have been on hold were held. This is about a six-week period that the policy was in place for.

Kevin: So not a deprescribing initiative, to be clear. Didn’t use that word; wasn’t described in that way. It was instituted for a very different reason than everything that was being talked about before.

Kevin: But, in the context of all that happening, I think a light bulb went over the head of the pharmacy leadership and the medical center director leadership, the regional directors who said, “Well, these medications are on hold. The residents haven’t been using them for weeks. Do we need to continue them when we lift the policy?”

Kevin: So in the moment, what I referred to as an ad hoc deprescribing initiative, they started communicating to the providers, “We’re going to not restart this medication when we lift the whole policy. Not even necessarily calling it a discontinuing, but we’re not going to restart the medication. Do you object to that?”

Kevin: So again, it was an opt-out where if you don’t really want us to restart the medication, it’s going to be discontinued. Then at the end of the hold policy, about half of the medications that were on hold were discontinued.

Kevin: Even though it wasn’t really envisioned as such at the beginning of the project, it ended up being, in some sense, a relatively successful deprescribing initiative, but done in a very unusual circumstance.

Alex: In fact, that might be the most wildly successful deprescribing initiative that I’ve ever heard about. Is that fair?

Kevin: Yeah. I mean, we didn’t do a survey of the literature to see what’s the highest proportion of medications as part of an initiative. So I can’t speak to it; probably Liz can, or maybe some of the others can say whether that’s a very high number or low number.

Alex: Yeah. I mean, Liz, Ariel, are you surprised by the degree of success of this policy change?

Elizabeth: Yeah. I mean, Kevin, I’m looking at your abstract now. I think it’s striking how effective it was at unloading people’s treatment burden with these unnecessary medications.

Eric: Yeah. I think it’s fascinating. There’s the medication holding period, but really looking at the medication discontinued, half the people had their multivitamins discontinued. 65%, two-thirds, had their histaminergics discontinued. Statins, half. PPIs, more than half. Probiotics, 72%. Other vitamin supplements, 51%. Docusate, huge one. Two-thirds.

Alex: Whoo!

Eric: Stop the drug that doesn’t work.

Alex: All mush and no push.

Eric: Yeah. Fish oil, 58%. The numbers are just striking, from just putting this hold on their medications for a period of time.

Kevin: Yes, and I think that is a key point. That’s like a selection of the people that had already effectively not been taking it for six weeks.

Eric: Yeah.

Kevin: That discontinue rate that you’re describing. So it’s not as if like out of everybody in the home 70% had their Docusate discontinued. It’s more like of the people who we placed on hold, most of them, it was discontinued. And in most of [inaudible 00:34:35]-

Eric: You said about half were put on hold?

Kevin: A little less than half. Yeah. Yeah, I think it was 41%, if I remember right. Exactly.

Ariel: I-

Kevin: It comes out to four or 5,000 unique orders of medications in the whole nursing home operator.

Ariel: For me, it also just gets back to what we were talking about a minute ago: the culture change. Because I think in trying to develop deprescribing interventions, we’re so concerned about stopping things that might potentially be necessary, like a statin.

Ariel: Or even when we’re looking back at the results and talking to people and debriefing and doing interviews after these studies. What we commonly hear is people saying, “I’m afraid to stop something that someone else started,” or, “I’m afraid if I stop the statin, someone might have a stroke three weeks later.” But here, these were considered unnecessary and were just stopped. As far as we know, it was okay.

Ariel: But I just feel the culture change … we just go through such great lengths to keep people on medicines.

Eric: Yeah. And Kevin-

Alex: Oh, go ahead.

Kevin: I think the pandemic made a big difference with that calculus that was being described about risk-benefit. In this moment, the benefit of trying to relieve the burden of all the medication stops and the administration; limiting transmissibility of infection in this period, and the staffing burden was a big part of the calculus that, in another time and period, maybe other things would take precedent in the providers’ minds.

Kevin: So it’s a big consideration when you interpret the results of the study: is that was a very unique time in terms of what these nursing homes were dealing with.

Eric: I want to ask two questions. But before I get to my question about what can we learn about from this study, the first question is: how much did the … Can I call it deprescribing? The discontinuation or-

Kevin: Yeah.

Eric: … had to do with the type of patient that was cared for. Or the patient characteristics, versus the type of facility they were in? Or what type of facility?

Kevin: Right. We went into some detail about that in the paper. We do some statistical modeling to answer that question. And kind of the layman’s gist of it is that it was more about the facility than it was about the person.

Kevin: We present these figures in the paper where we show the spread of, if you were a person in facility A versus B, what was your likelihood of having your medication discontinued or not restarted? And it was wildly different based on facility.

Kevin: Some facilities, you’re approaching a hundred percent chance that that med was not going to be continued for you. But in other facilities, it was less than 50% chance. So a huge driver of whether things were restarted or not had to do with the facility itself versus person-level factors.

Alex: And that speaks to that point that Ariel was just talking about, about culture, right?

Kevin: Mm-hmm.

Alex: Because this institutional culture within this nursing home is different from the institutional culture in that nursing home.

Alex: Eric, you had another question?

Eric: My other question is this just a, “Hmm, that was an interesting period of life. Let’s move on”? Or what should we do with this information?

Kevin: Yeah. Yeah. I mean, I think the key question is, would this have had the same result, actually, if Liz did this trial today in new nursing homes outside? I mean, we’re still in the pandemic, but it’s not quite the same. Would we have seen the same result today?

Kevin: My intuition is it probably wouldn’t have had quite as large in effect as what we saw here. But there has not really been a trial like this where we tried a trial holding period with opt-out strategies, then tried to nudge the provider into just letting go of the thing. You know what I mean?

Kevin: So it is a novel approach that I think is worthy of investigation to show that it could work, and that it isn’t just a one-off unusual thing that happened in the early phase of the pandemic.

Kevin: In short, I do believe that this could work if you applied it in a more normal setting, so to speak.

Eric: Liz, what do you think?

Elizabeth: I think the blanket changes that the nursing homes had so much success with, to me, they sound a little pandemic specific in terms of the acceptance. But it makes me wonder a ton about other systematic changes that might be really effective.

Elizabeth: Let’s say that … I’m just making this up. That the default number of refills for a prescription for PPIs was not 12 months; it was two months instead. Or other changes that required action on the part of the provider to continue a medicine, rather than to discontinue it.

Alex: Oh, I like that. Right. There’s more of an opt-out with medicine refills so that each prescription is time-limited, in the sense that the refills don’t continue forever. I like that. We can’t always invoke these crisis standards of care, under which these changes took place.

Alex: And I just also want to come back to a quick point. The rationale for this hold was that we didn’t want nursing staff to have to go into patients’ rooms when there was no established benefit for the medications that were being held. Is that right, Kevin?

Kevin: That was a big driver of it. Yeah. Remember, this was an earlier part where transmission of the disease was not as well understood. It was quarantine; people were in quarantine at this point.

Eric: And PPEs were in limited supply. So donning and doffing was an issue too.

Kevin: That’s right. That’s right.

Eric: They’re very different times than now in a nursing home.

Eric: All right. Alex, is it okay if I ask one more question? I see you gearing up with your guitar.

Alex: Yeah.

Eric: Okay. Each of you have a little magic wand; it can do one thing around deprescribing. It’s running out of juice, so it doesn’t have more than one for each of you. What would you use that magic wand on to change either from a patient-provider policy, anything perspective? Liz, I’m going to start with you.

Elizabeth: I guess I don’t get to change culture with one swipe, but I might say that for every chronic medication prescription, the provider says, “You’re not going to need this forever, but you need it for a certain amount of time for X reason.”

Eric: Yeah. Even when starting a PPI, saying how long that they may need it for.

Elizabeth: Right.

Eric: Or for, like, Colace, saying, “You don’t even need it right now.”

Elizabeth: So start at the prescribing moment,

Eric: Ariel, what’s yours on?

Ariel: Gosh, I was going to say the same thing. And I was going to use my little magic wand to change the culture of prescribing, so that we’re not so quick to start medicines.

Ariel: Basically I think we have set up this expectation that there’s a pill for everything, and that medicines have no harms. I wish I could change that expectation.

Eric: Well, it’s interesting. The only medicine I could think of, like antibiotics, we usually think duration: how long somebody needs to be on a medicine?

Eric: We don’t really think about that for starting a lot of these other medicines is duration. How long does somebody need to be on a PPI? A histamine med? All these other things that they’re taking? Kevin?

Kevin: I can take a more data-nerdy perspective on it. This is happening, so I wouldn’t say it’s a magic wand. But maybe it’s not something that’s happening right away. Is that I think a lot more data on nursing home prescribing would bring this into the light a little bit.

Kevin: Brown and some of our collaborative partners are working really hard to just help unify a lot of the EHR data that’s available from the nursing home setting to conduct pragmatic trials, to report on interventions that are done ad hoc, like this medication hold policy.

Kevin: And I think when that data becomes more easily available and people can report on what’s happening and the impacts of different interventions, it really helps increase the comfort level of prescribers and help move that culture change along.

Kevin: So that’s my magic wand: is to really help bring that data into the public eye so we can use it.

Eric: Great. All right, this magic wand has a tiny bit of juice. I’m going to use it to have Alex sing a little bit more of Pills. [laughter]

Alex: (singing)

Eric: Liz, Kevin, Ariel, huge thank you for being on this podcast.

Kevin: Thank you.

Ariel: Thank you so much.

Elizabeth: Thanks a lot for having us.

Eric: And thank you to Archstone Foundation for your continuous support, and to all of our listeners.

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