A Randomized Controlled Trial to Deprescribe for Older Patients With Polypharmacy

Not Applicable

Completed

Conditions: Polypharmacy
Care Transitions
Geriatric Syndromes

Registration Number: NCT02979353

Lead Sponsor: Vanderbilt University Medical Center

Brief Summary: This randomized, controlled trial will evaluate the effects of an intervention to reduce exposure to medications among hospitalized older adults discharged to skilled nursing facilities (SNFs). The goal of the intervention is to safely deprescribe medications, as defined by dose reductions and stopped medications, based on a combination of clinical criteria and patient preferences. The investigators will evaluate the effects of the intervention on the total number of medications prescribed to patients at hospital and SNF discharge and at home 90-days after SNF discharge along with the prevalence of eight geriatric syndromes, medication adherence, and health status.

Detailed Description: This randomized, controlled trial will evaluate the effects of an intervention to reduce exposure to medications among hospitalized older adults discharged to skilled nursing facilities (SNFs). This study will be conducted in one university-affiliated hospital and 14 area SNFs to enroll approximately 1,300 total participants across five project years. Patients discharged to SNF represent the largest segment of Medicare beneficiaries discharged to post-acute care services and are a particularly high risk group for loss of independence and other poor clinical outcomes. This investigative team recently completed a Centers for Medicare and Medicaid Services (CMS) Innovation Award, which provides strong preliminary data related to the prevalence of polypharmacy and the relationship between polypharmacy and geriatric syndromes (e.g., medications associated with falls) in this patient population. Based on these data, the investigators developed a structured deprescribing intervention protocol ("Shed-Meds") coupled with standardized screening assessments for eight geriatric syndromes to be implemented in the hospital and continued during the SNF stay. The goal of the intervention is to safely deprescribe medications, as defined by dose reductions and stopped medications, based on a combination of clinical criteria and patient preferences. This trial will evaluate the effects of this intervention on medication exposure, medication adherence, geriatric syndromes, and health status across the care transitions from hospital to SNF to home to include a 90-day follow-up period after SNF discharge. The overarching hypothesis is that reducing medications for older patients across the continuum of care will favorably impact geriatric syndromes.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 372

Inclusion Criteria

Hospitalized at Vanderbilt University Medical Center
Medicare-eligible
Discharged from VUMC to a post acute care facility
Has polypharmacy as defined by > 5 medications
Able to self-consent or has a proxy (surrogate)
Speaks English (due to interview-based assessments)
Primary home residence within one of 9 surrounding counties (due to home visit during follow-up phase)

Exclusion Criteria

Resides in long-term care
Is currently on hospice or otherwise has a limited life expectancy (< 6 months).
Enrolled in a clinical drug trial
Has Stage IV Cancer Diagnosis
Incarcerated or homeless
Unable to self-consent and does not have a surrogate

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Primary Outcome Measures

Name	Time	Method
Total Number of Medications	Hospital Discharge, Post-Acute Care Discharge, and 90 days after discharge from the PAC	The number of medications a participant is taking. This includes all prescribed and over-the-counter medications and both scheduled and as-needed (PRN) medications.

Secondary Outcome Measures

Name	Time	Method
Total Drug Burden Index (DBI): Anticholinergic and Sedative Drug	Hospital Discharge, Post-Acute Care Discharge, and 90 days after discharge from PAC	A Drug Burden Index (DBI) score is calculated for each anticholinergic and sedative medication by dividing the individual medication's prescribed daily dose by the sum of the minimum effective dose (per FDA minimum recommended dose) and the patient's daily dose. The score range for each individual medication is 0 to 1, and the Anticholinergic \& Sedative DBI reported is the sum of the individual medication scores. The Anticholinergic \& Sedative DBI has a minimum score of 0 and no maximum. Higher scores indicate a higher drug burden (i.e., lower score is a better outcome).