Abstract
Background – Deprescribing, or the intentional discontinuation or dose-reduction of medications, is a patient-centered approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications.Methods – We conducted a pre-post with historical control group pilot feasibility trial at an urban VA medical center. We included patients in one of two medication-based cohorts: 1) proton pump inhibitor (PPI), defined as use of any dose for 90 consecutive days, or 2) hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c <7%; and age >65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome.Results – The 348 subjects (253 intervention, 95 historical control) were primarily age >65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p=0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p=0.001). Conclusions – Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method that successfully increased both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the ability of patients to drive medication prescribing changes within clinical encounters has potential to reduce drug burden and decrease adverse drug effects and harms.
Prioritizing Examination-Centered Over Patient-Centered Dose Reduction: A Hazard of Institutional “Benchmarking”