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A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic

Published:September 25, 2019DOI:https://doi.org/10.1016/j.japh.2019.09.011

      Abstract

      Objective

      To develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit (AWV) to make deprescribing recommendations targeted at potentially inappropriate medications (PIMs) in seniors.

      Setting

      A family medicine patient-centered medical home (PCMH) clinic in Buffalo, NY.

      Practice description

      Implementation and evaluation of a pilot program incorporating a pharmacist-provided medication review targeting PIMs in seniors as part of a Medicare AWV.

      Practice innovation

      A community pharmacy–based clinical pharmacist provided face-to-face medication reviews for patients older than 65 years as part of their AWV with a focus on deprescribing PIMs. No clinical pharmacy service existed at the practice when this program was implemented.

      Evaluation

      Identified PIMs, pharmacist recommendations, recommendation acceptance rate, time spent on intervention, health care utilization at 6 months postvisit, and barriers to implementation.

      Results

      Of the 21 patients enrolled, 13 unique patients received a total of 20 deprescribing recommendations from the pharmacist. The overall acceptance rate for pharmacist recommendations was 20%. The pharmacist spent a mean (± SD) of 34 (± 6) minutes per patient encounter. One patient in the intervention group was hospitalized, and 1 was seen in the emergency department (ED) during the 6-month follow-up period compared with 1 patient in the control group who had an ED visit. We identified multiple logistical and organizational barriers to the implementation of the intervention.

      Conclusion

      In this prospective pilot study, a workflow to include a pharmacist medication review to facilitate deprescribing in the primary care setting was tested. We encountered several barriers to integrating the pharmacist into the AWV workflow to deliver the intervention. Future pragmatic clinical trials are warranted to improve provider awareness and comfort with deprescribing PIMs in seniors.
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      References

        • Molokhia M.
        • Majeed A.
        Current and future perspectives on the management of polypharmacy.
        BMC Fam Pract. 2017; 18: 70
        • Lund B.C.
        • Carnahan R.M.
        • Egge J.A.
        • Chrischilles E.A.
        • Kaboli P.J.
        Inappropriate prescribing predicts adverse drug events in older adults.
        Ann Pharmacother. 2010; 44: 957-963
        • Albert S.M.
        • Colombi A.
        • Hanlon J.
        Potentially inappropriate medications and risk of hospitalization in retirees: analysis of a US retiree health claims database.
        Drugs Aging. 2010; 27: 407-415
        • Scott I.A.
        • Hilmer S.N.
        • Reeve E.
        • et al.
        Reducing inappropriate polypharmacy: the process of deprescribing.
        JAMA Intern Med. 2015; 175: 827-834
        • Reeve E.
        • Gnjidic D.
        • Long J.
        • Hilmer S.
        A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice.
        Br J Clin Pharmacol. 2015; 80: 1254-1268
        • Thompson W.
        • Lundby C.
        • Graabaek T.
        • et al.
        Tools for deprescribing in frail older persons and those with limited life expectancy: a systematic review.
        J Am Geriatr Soc. 2019; 67: 172-180
        • Hanlon J.T.
        • Weinberger M.
        • Samsa G.P.
        • et al.
        A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.
        Am J Med. 1996; 100: 428-437
        • Martin P.
        • Tamblyn R.
        • Benedetti A.
        • Ahmed S.
        • Tannenbaum C.
        Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial.
        JAMA. 2018; 320: 1889-1898
        • Navy H.J.
        • Weffald L.
        • Delate T.
        • Patel R.J.
        • Dugan J.P.
        Clinical pharmacist intervention to engage older adults in reducing use of alprazolam.
        Consult Pharm. 2018; 33: 711-722
        • Tamblyn R.
        • Eguale T.
        • Buckeridge D.L.
        • et al.
        The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial.
        J Am Med Inform Assoc. 2012; 19: 635-643
        • Tannenbaum C.
        • Martin P.
        • Tamblyn R.
        • Benedetti A.
        • Ahmed S.
        Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.
        JAMA Intern Med. 2014; 174: 890-898
        • Ammerman C.A.
        • Simpkins B.A.
        • Warman N.
        • Downs T.N.
        Potentially inappropriate medications in older adults: deprescribing with a clinical pharmacist.
        J Am Geriatr Soc. 2019; 67: 115-118
        • Garfinkel D.
        • Mangin D.
        Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.
        Arch Intern Med. 2010; 170: 1648-1654
        • Dills H.
        • Shah K.
        • Messinger-Rapport B.
        • Bradford K.
        • Syed Q.
        Deprescribing medications for chronic diseases management in primary care settings: a systematic review of randomized controlled trials.
        J Am Med Dir Assoc. 2018; 19: 923-935.e2
        • Iyer S.
        • Naganathan V.
        • McLachlan A.J.
        • Le Couteur D.G.
        Medication withdrawal trials in people aged 65 years and older: a systematic review.
        Drugs Aging. 2008; 25: 1021-1031
        • Cooper J.A.
        • Cadogan C.A.
        • Patterson S.M.
        • et al.
        Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review.
        BMJ Open. 2015; 5: e009235
        • Gray S.L.
        • Hart L.A.
        • Perera S.
        • Semla T.P.
        • Schmader K.E.
        • Hanlon J.T.
        Meta-analysis of interventions to reduce adverse drug reactions in older adults.
        J Am Geriatr Soc. 2018; 66: 282-288
        • Wallis K.A.
        • Andrews A.
        • Henderson M.
        Swimming against the tide: primary care physicians' views on deprescribing in everyday practice.
        Ann Fam Med. 2017; 15: 341-346
        • Ailabouni N.J.
        • Nishtala P.S.
        • Mangin D.
        • Tordoff J.M.
        Challenges and enablers of deprescribing: a general practitioner perspective.
        PLoS One. 2016; 11: e0151066
        • Reeve E.
        • Low L.F.
        • Hilmer S.N.
        Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study.
        Br J Gen Pract. 2016; 66: e552-e560
        • Peterson G.M.
        • Naunton M.
        • Deeks L.S.
        • Kosari S.
        • Jackson S.L.
        • Boom K.
        Practice pharmacists and the opportunity to support general practitioners in deprescribing in the older person.
        J Pharm Pract Res. 2018; 48: 183-185
        • American Pharmacists Association
        Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing.
        American Pharmacists Association, Washington, DC2018
        • Galvin S.L.
        • Grandy R.
        • Woodall T.
        • Parlier A.B.
        • Thach S.
        • Landis S.E.
        Improved utilization of preventive services among patients following team-based annual wellness visits.
        N C Med J. 2017; 78: 287-295
        • Warshany K.
        • Sherrill C.H.
        • Cavanaugh J.
        • Ives T.J.
        • Shilliday B.B.
        Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic.
        Am J Health Syst Pharm. 2014; 71: 44-49
        • Wilson C.G.
        • Park I.
        • Sutherland S.E.
        • Ray L.
        Assessing pharmacist-led annual wellness visits: interventions made and patient and physician satisfaction.
        J Am Pharm Assoc (2003). 2015; 55: 449-454
        • Thomas M.H.
        • Goode J.V.
        Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office.
        J Am Pharm Assoc (2003). 2014; 54: 427-434
        • American Geriatrics Society 2015 Beers Criteria Update Expert Panel
        American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2015; 63: 2227-2246
        • Haig K.M.
        • Sutton S.
        • Whittington J.
        SBAR: a shared mental model for improving communication between clinicians.
        Jt Comm J Qual Patient Saf. 2006; 32: 167-175
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making—pinnacle of patient-centered care.
        N Engl J Med. 2012; 366: 780-781
        • Doellner J.F.
        • Dettloff R.W.
        • DeVuyst-Miller S.
        • Wenstrom K.L.
        Prescriber acceptance rate of pharmacists’ recommendations.
        J Am Pharm Assoc (2003). 2017; 57: S197-S202
        • Doucette W.R.
        • McDonough R.P.
        • Klepser D.
        • McCarthy R.
        Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy.
        Clin Ther. 2005; 27: 1104-1111
        • Hata M.
        • Klotz R.
        • Sylvies R.
        • et al.
        Medication therapy management services provided by student pharmacists.
        Am J Pharm Educ. 2012; 76: 51
        • Mott D.A.
        • Martin B.
        • Breslow R.
        • et al.
        Impact of a medication therapy management intervention targeting medications associated with falling: results of a pilot study.
        J Am Pharm Assoc (2003). 2016; 56: 22-28
        • Kelley J.M.
        • Kraft-Todd G.
        • Schapira L.
        • Kossowsky J.
        • Riess H.
        The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials.
        PLoS One. 2014; 9: e94207
        • Smith M.A.
        Implementing primary care pharmacist services: go upstream in the world of value-based payment models.
        Res Soc Adm Pharm. 2017; 13: 892-895
        • Whitman A.
        • DeGregory K.
        • Morris A.
        • Mohile S.
        • Ramsdale E.
        Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study.
        Support Care Cancer. 2018; 26: 4105-4113

      Biography

      Collin M. Clark, PharmD, BCPS, NRSA T32 Postdoctoral Research Fellow, Primary Care Research Institute, Department of Family Medicine, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY

      Biography

      Susan A. LaValley, PhD, MLS, MA, Research Assistant Professor, Department of Family Medicine, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY; At the time of study: NRSA T32 Postdoctoral Research Fellow, Primary Care Research Institute, Department of Family Medicine, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY

      Biography

      Ranjit Singh, MB BChir, MBA, Associate Professor, Vice Chair for Research, and Director, Primary Care Research Institute, Department of Family Medicine, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY

      Biography

      Esra Mustafa, PharmD, BCACP, Care Manager Pharmacist, Millennium Collaborative Care, Buffalo, NY; At the time of study: Clinical Pharmacist, Mobile Pharmacy Solutions, Buffalo, NY

      Biography

      Scott V. Monte, PharmD, Clinical Assistant Professor, State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences and Chief Clinical Officer, Mobile Pharmacy Solutions, Buffalo, NY

      Biography

      Robert G. Wahler Jr., PharmD, CPE, BCGP, FASCP, Clinical Assistant Professor, State University of New York at Buffalo School of Pharmacy and Pharmaceutical Science, Buffalo, NY and Director, Clinical Pharmacy Services, Niagara Hospice, Lockport, NY