Mindfully “Passing the Rx Baton” After Acute Care

Update on Shed-MEDS, the largest geriatric deprescribing intervention trial to date.

Geriatric patients taking five or more medications (defined as polypharmacy) are at increased risk of geriatric syndromes such as delirium, cognitive impairment, depression, nutrition risk/weight loss and falls. A team of Vanderbilt University Medical Center researchers tackling the polypharmacy challenge have passed the halfway point of the largest acute care deprescribing trial to date.

Results will reveal the impact of mindful prescription review and intervention as older patients leave acute care to go to a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Approximately 40 percent of patients transferred from acute care in the hospital to SNFs never go home, and over 20 percent return to the hospital within the next 30 days. As many as 83 percent of these older patients are prescribed 10 or more medications.

Ed Vasilevskis, M.D., who serves as section chief of hospital medicine at Vanderbilt, and Sandra Simmons, Ph.D., director of Vanderbilt Center for Quality Aging, are leading the National Institute of Aging-sponsored Shed-MEDS study.

”Once a patient’s acute care crisis has passed, there is a systemic tendency to lose sight of many of the underlying conditions that may affect recovery and ongoing quality of life.”

”Once a patient’s acute care crisis has passed, there is a systemic tendency to lose sight of many of the underlying conditions that may affect recovery and ongoing quality of life,” Vasilevskis said. “Adding on prescription drugs is a primary case in point. With multiple physicians and facilities in play, sometimes there is no one manning the helm.”

Study Intervention

Shed-MEDS is a randomized, controlled trial aiming to enrolling 1,300 patients. Adjusting for expected mortality, the trial will compare outcomes between deprescribed and control cohorts.

All subjects are polypharmacy patients over age 50 discharged from Vanderbilt’s adult hospital to an SNF or IPR. A clinical pharmacist or geriatric NP is assigned to review medications prior to discharge. Using deprescribing rationales such as “no indication for the medication,” “indication not clear,” “multiple drugs for the same indication” or “potential drug-disease interaction,” the pharmacist or NP makes recommendations to the patient and consults with the patient’s providers to make agreed-upon adjustments. They follow up via phone at seven days after transfer to the SNF or IPR, again at 60 days, and with a home visit at 90 days.

The primary endpoint is change in total number of medications. The secondary endpoint is the impact of medication reductions on adherence, geriatric syndromes and functional health status.

“Our goal is to identify opportunities to stop or lower the dose or frequency of drugs where clinical evidence and patient preferences support this,” Vasilevskis said.

Toward a Lower Error Rate

Polypharmacy increased from 8.2 percent to 15 percent between 1999 and 2012. Among the 45 percent of older hospitalized patients discharged to SNFs with polypharmacy, more than 90 percent take at least one inappropriate medication.

Medication errors commonly occur because patients remain on a drug that was appropriate during their hospital stay or continue on a pre-hospitalization drug that has been replaced by another. Reviewing a patient’s medication list at acute care intake can be fraught with complications and is often a secondary priority. In the handoff to an SNF or IRF, other opportunities for global review may fall under the radar.

“Passing the Rx baton with careful attention toward ensuring the ‘right’ list is compiled is an inherent goal of the Shed-MEDS research,” Vasilevskis says. “By developing systematic means of assuring this, we can help patients and contribute to more cost-effective use of healthcare resources.”