Drug Reduction in Older Patients: The DROP Trial

Overview and Specific Aims Polypharmacy, defined as five or more medications, is common in older patients discharged to skilled nursing facilities (SNFs) and is associated with adverse health outcomes. As part of a recent VA project, the investigators prospectively collected medication data for 134 hospitalized, older Veterans. These data showed that, on average, 14.2 medications were ordered for Veterans discharged to SNF, which included 2.5 medications newly prescribed in the hospital that met criteria for being potentially inappropriate medications (PIMs). Moreover, 75% of these Veterans had two or more geriatric syndromes. Geriatric syndromes are clinical conditions common in older adults such as cognitive impairment, unintentional weight loss and falls. The co-occurrence of multiple syndromes is associated with loss of independence and higher healthcare utilization. All Veterans with polypharmacy also had one or more medications associated with geriatric syndromes. The prevalence of polypharmacy and multiple geriatric syndromes may partially explain why these patients often have poor health outcomes after SNF discharge. Recent data suggests that only 28% of patients discharged from SNF are living at home 100 days later, and 35% experience an adverse drug event.

There is a dearth of evidence related to the management of multiple co-existing geriatric syndromes, and few interventions have been implemented to reduce medications while also monitoring health outcomes. The relationship between polypharmacy, adverse drug events and geriatric syndromes in the VA population supports the rationale for an intervention focused on deprescribing medications before hospital discharge. The investigators have pilot-tested a multifaceted intervention (Drug Reduction in Older Patients, DROP) to engage patients and providers to reduce the number and/or dose of medications prior to hospital discharge. The proposed randomized, controlled trial is powered to evaluate the effect of this intervention on a reduction in medications as defined by the total number of prescribed medications, the number of PIMs, anticholinergic and sedative drug burden and the number of medications associated with geriatric syndromes. In addition, the investigators will collect relevant data on the prevalence and severity of geriatric syndromes and other clinical outcomes. The investigators also will use a hybrid research design to evaluate both effectiveness and implementation issues to better inform future adoption and sustainability. Our overarching hypothesis is that a hospital-based intervention to safely reduce the total number of medications represents the most feasible way to impact multiple health-related outcomes among older Veterans. Our Specific Aims reflect the primary outcomes that are the focus of the analyses, although the investigators also will measure secondary outcomes related to VA healthcare utilization and patient safety:

Specific Aim 1: Implement a patient-centered deprescribing intervention (DROP) in the hospital to reduce the total number of medications Veterans are prescribed at hospital discharge.

Specific Aim 2: Document the effects of a Veteran-centered deprescribing intervention (DROP) on medication adherence, health status, and geriatric syndromes.

Specific Aim 3: Evaluate intervention implementation to inform future adoption and sustainability.