The Case for Human-Centered Research on the Complex Patient Journey of Deprescribing
TimeWednesday, April 1412:50pm - 1:10pm EDT
LocationPatient Safety Research and Initiatives
DescriptionThe goals of this presentation are to analyze current models of deprescribing—defined as “the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes” (Reeve et al., 2015)—and summarize existing interventions to promote deprescribing among older adults. We hypothesize that one of the reasons for some of the gaps and opportunities in this area is due to the overly simplistic understanding of the deprescribing process. We assert that the deprescribing process needs to be viewed as work performed by the patient and reframed to focus on the patient journey.
Deprescribing is an important aspect of medication optimization, especially when considering older adult populations, as many older individuals take a large number of medications, some of which may no longer be medically necessary, or in some cases, even harmful for the patient. This phenomenon, called polypharmacy, has been shown to increase the risks of adverse drug events, negative drug interactions, medication non-adherence, falls, and other negative health consequences (Maher et al., 2014). While various interventions have been developed and tested with the purpose of promoting, facilitating, or improving deprescribing among older adults to reduce polypharmacy, we will demonstrate that the majority of these interventions have targeted clinicians and have had limited success for improving patient quality of life or reducing adverse events such as hospitalizations, falls, or overall mortality (Bloomfield et al., 2020; Page et al., 2016; Rankin et al., 2018).
This lack of intervention success may be attributable to the overly simplistic view of the deprescribing process in the literature. Collectively, our research team has 40 years of experience conducting research related to various aspects of deprescribing and medication safety. We will show that current models that outline deprescribing are largely from a clinician perspective, and focus on actions taken by healthcare professionals (e.g. comprehensive medication reviews, patient consultations) at a single point in time. This is likely why the majority of interventions reported in the literature target clinicians.
We assert that is important that the deprescribing process be seen for its complexity. Not only is it a process that unfolds over time, sometimes on a scale that is as long as the life of a patient, but there are more factors involved than having a clinician follow a set of steps to optimize a patient’s medications. Both clinicians and, most especially, patients need to make many decisions throughout this process at various points in time. Without patient cooperation, effective deprescribing cannot occur, indicating that successful deprescribing should focus on the wants and needs of the patient, empower the patient to make decisions and take control of their health, and/or focus on the journey of the patient through the process—as opposed to the current assumptions of the process being driven by clinicians. It follows that, once the patient journey through the deprescribing process is understood, more effective deprescribing interventions, for both patients and clinicians, can be developed and deployed.
In this presentation, we critically analyze current models and understanding of the deprescribing process by summarizing past work in this area. We summarize existing deprescribing interventions for older adults and whom they target (clinician, patient, or both) to identify gaps in the existing work. We also argue that the process of deprescribing needs to be examined through the lens of patient ergonomics (Holden et al., 2020) and medication transitions (Holden & Abebe, 2021) to reframe it as a patient-driven process. This topic is important as it will demonstrate to attendees how a deeper understanding of the problem may yield more effective, innovative solutions to enhance patient care.
Bloomfield, H. E., Greer, N., Linsky, A. M., Bolduc, J., Naidl, T., Vardeny, O., MacDonald, R., McKenzie, L., & Wilt, T. J. (2020). Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. Journal of General Internal Medicine, 35(11), 3323–3332. https://doi.org/10.1007/s11606-020-06089-2
Holden, R. J., & Abebe, E. (2021). Medication transitions: Vulnerable periods of change in need of human factors and ergonomics. Applied Ergonomics, 90. https://doi.org/10.1016/j.apergo.2020.103279
Holden, R. J., Cornet, V. P., & Valdez, R. S. (2020). Patient ergonomics: 10-year mapping review of patient-centered human factors. Applied Ergonomics, 82, 102972. https://doi.org/10.1016/j.apergo.2019.102972
Maher, R. L., Hanlon, J. T., & Hajjar, E. R. (2014). Clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety, 13(1). https://doi.org/10.1517/14740338.2013.827660
Page, A. T., Clifford, R. M., Potter, K., Schwartz, D., & Etherton-Beer, C. D. (2016). The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. British Journal of Clinical Pharmacology, 583–623. https://doi.org/10.1111/bcp.12975
Rankin, A., Cadogan, C. A., Patterson, S. M., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Highes, C. (2018). Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews, 9. https://doi.org/10.1002/14651858.CD008165.pub4.
Reeve, E., Gnjidic, D., Long, J., & Hilmer, S. (2015). A systematic review of the emerging definition of “deprescribing” with network analysis: Implications for future research and clinical practice. British Journal of Clinical Pharmacology, 80(6), 1254–1268. https://doi.org/10.1111/bcp.12732