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When less is more: Deprescribing


Kevin Baran, MD, MPH, HMDC, OptumCare Senior Partner, Regional Medical Director
ProHealth Physicians

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ProHealth Physicians, part of OptumCare®, is a physician-led medical group caring for more than 345,000 active patients with 350 primary and specialty care providers at 85 locations in Connecticut.

Lowering adverse effects of proton pump inhibitors

Evidence shows that leaving the doctor’s office with a prescription in hand increases patient satisfaction with their visit.1 

Even though patient satisfaction is crucial to the success of a practice, physicians and pharmacists at ProHealth Physicians, part of OptumCare, are working to reduce chronic medications when clinically sound. 

They're using the latest evidence and patient-centered education in order to improve clinical outcomes and prevent harm to their patients.

Longer medication lists

As pharmaceutical solutions have grown, medication lists have lengthened. Recent studies find that patients over age 65 take a daily average of three to five pharmacy-dispensed medications.2 

The risk of adverse drug effects (ADEs) increases with the number of prescribed medications. At two medications prescribed, the risk for ADEs is thirteen percent. When the number rises to seven prescriptions, risk multiplies to eighty-two percent.3 

 

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Lessons from medication reconciliation

When following up on patients recently discharged from the hospital, they were surprised by the large number of proton pump inhibitor (PPI) prescriptions patients brought home. 

PPIs are used in the hospital setting to manage anti-inflammatory or steroid-induced gastritis as well as for stress ulcer prophylaxis. There is little available evidence to suggest continued home use.4 

The practitioners’ realization during medication reconciliation brought ProHealth pharmacist Suzanne Florczyk, Pharm.D., on board. 

“We already had an interest in reducing the number of medications many of our seniors take, as the side effects can be debilitating," says Florczyk. "Starting a program of de-prescribing with PPIs made sense.”

PPI-associated adverse drug effects (ADEs) include electrolyte disturbances, as their use affects the absorption of vitamins and minerals. Following the same pathophysiology, there is also a higher risk for bone fractures. 

 

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More recent evidence suggests an increased risk of community acquired pneumonia and clostridium difficile (C. difficile).5 A greater risk of C. difficile and pneumonia in the elderly population strongly supports avoiding these drugs.

Education as intervention

ProHealth staff education was done through the pharmacy newsletter and by holding organized education sessions and soliciting feedback from a multidisciplinary team of clinicians. 

Given the background education, clinicians would then begin to work with their patients to reduce unnecessary use of PPIs.

The decision to stop prescribing a pill that may cause critical illness seems an easy enough objective. However, for a patient struggling daily with GERD pain, understanding the trade-off of present relief for a future benefit is difficult. 

Trust in their ProHealth clinicians and a pharmacy-developed titration strategy for PPI de-escalation helped build patient confidence that their symptoms, including potential rebound acid secretion, would be cared for.

Critical to the deprescribing strategy was latitude for good clinical judgement and patient-specific care. 

Weighing risks and benefits, looking for behavioral modifications that fit patient lifestyle, and extending the taper to a comfortable interval and period were all important considerations.

The ProHealth initiative involving de-prescribing PPIs began in the Spring of 2017. Past figures show that 30,000 ProHealth patients have been diagnosed with GERD. Of those, 41 percent are receiving a PPI. 

A few months into the project, there is already evidence of a change in prescribing habits. The entire team, from intake nurses to primary care physicians, seeks opportunities to talk with patients about replacing a higher risk drug with behavior change or substitution medication. 

Slimming the drug regimen is a pharmacy-led measure proven to impact patient outcomes positively while reducing medication load, both in adverse effects and cost burden. As a prominent physician remarked, “as a practicing doc, I think about PPIs at every patient interaction.” 

The multidisciplinary team at ProHealth continues to aim for better quality care that improves safety, health, and affordability of care. Their efforts have shown that indeed patients can be better satisfied while leaving the doctor’s office with one less prescription. 

 

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This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice. 

 

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  1. Ashworth, M., White, P., Jongsma, H., Schofield, P., & Armstrong, D. (2016). Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data. Br J Gen Pract, 66(642), e40-e46.
  2. Fulton, M. M., & Riley Allen, E. (2005). Polypharmacy in the elderly: a literature review. Journal of the American Association of Nurse Practitioners, 17(4), 123-132.
  3. Prybys, K., & Gee, A. (2002). Polypharmacy in the elderly: clinical challenges in emergency practice. Part, 1, 145-151.
  4. Ahrens, D., Chenot, J. F., Behrens, G., Grimmsmann, T., & Kochen, M. M. (2010). Appropriateness of treatment recommendations for PPI in hospital discharge letters. European journal of clinical pharmacology, 66(12), 1265-1271.
  5. Ibid.