BOSTON — Sending patient-directed educational materials prior to primary care visits proved to be an effective, low-tech intervention to increase deprescribing of potentially low-value and high-risk medications, according to a new VA study.
“Incorporating patient-directed educational strategies can increase the clinical uptake of deprescribing,” wrote the authors of the study led by the VA Boston Healthcare System and Harvard Medical School. “With healthcare increasingly prioritizing patient-centered delivery models, this intervention can be easily disseminated to have timely impact on quality, safety and satisfaction among patients, clinicians and healthcare systems.”
The study published in JAMA Internal Medicine suggested that patient-directed educational materials “are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks.”1
The study team, which also included representatives from the VA Pittsburgh and Greater Los Angeles healthcare systems, sought to examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit—proton pump inhibitors, in this case—or high-risk medications—high-dose gabapentin and diabetes agents with hypoglycemia risks for purposes of the study.
The pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct U.S. Veterans Affairs (VA) medical centers from April 2021 to October 2022.
The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to more than 2,500 eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same 1-3 primary care physicians (PCPs) at the same sites 1 year prior to the study intervention served as controls, also numbering about 2,500.
Defined as the primary binary outcome variable was deprescribing 6 months after the intervention. That was based on complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data.
Results indicated that the overall rate of deprescribing among the intervention cohort, with 2,539 participants, was 29.5% compared with 25.8% among the 2,532 controls.
In an unadjusted model, the intervention cohort was found to be statistically significantly more likely to be involved in deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = 0.02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = 0.008).
The authors reported that deprescribing prevalence between the intervention and control cohorts—proton pump inhibitors: 29.4% vs. 25.4%; gabapentin: 40.2% vs. 36.2%; hypoglycemia risk: 27.3% vs. 25.1%—showed no statistical difference by medication group.
“This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups,” the researchers pointed out.
Background information in the article advised, “Inappropriate medication use and polypharmacy are common and costly problems plaguing patients, clinicians, and health care systems.1 National campaigns, such as the American Board of Internal Medicine’s Choosing Wisely campaign, attempt to decrease inappropriate medication use and polypharmacy, but medication safety issues continue to be widespread. Nearly 1 in 5 (17.1%) U.S. adults take 5 or more medications, a commonly accepted threshold for polypharmacy, escalating to 50% among older adults with chronic conditions.”
The authors added that, while deprescribing has the potential to reduce low-value medication use, it is not routinely adopted into clinical practice, noting, “Indeed, medication management can be a highly complex interplay between patients, clinicians, and the health care system, making partnering with patients integral to deprescribing.”
The investigators called their observed findings “clinically meaningful,” adding that those aligned with other evidence that patient-directed education interventions might spur shared decision-making. “Specific to this intervention, disseminating medication brochures ahead of a scheduled PCP visit may serve as a priming tool to activate patients to initiate deprescribing discussions with clinicians,” they explained.
They also discussed how—while a significant increase in deprescribing occurred—the effect size was small and less than that seen in some other deprescribing trials. Why? They responded, “The intervention was low intensity, and deprescribing interventions may need to be multifaceted or more resource-intensive to have a larger impact. The medications targeted may have higher rates of baseline deprescribing than medications addressed in other studies (e.g., benzodiazepines).”
In the study, the hypoglycemia-risk medication group was the least likely to experience deprescribing at 6 months.” Deprescribing may be more complex for diabetes because glycemic control is often a quality metric and clinician and patient fear of worsening glycemic control is common,” the authors explained. “In other deprescribing contexts, such as multiple sclerosis, fear of worsening disease control is a common barrier to deprescribing. Conversely, deprescribing was highest for gabapentin in both the historical control and intervention cohorts, with several possible reasons. Gabapentin is often prescribed off-label and, even in instances where there is supporting evidence, the number needed to treat is high, with few experiencing improvement in pain.”
They added that some gabapentin indications, such as for post-operative pain, are intended to be time-limited. Because of that, the gabapentin brochures could facilitate deprescribing of the medication, because it is symptom-based medication. Users are more likely to be willing to desprescribe, the study posited, if it is intended for short-term use or is ineffective.
The authors suggested that some characteristics of VA healthcare might facilitate deprescribing of potentially low-value or high-risk medications, including the mission to provide “Whole Health” treatments for chronic conditions. All of the brochures stressed the importance of discussing medication changes with PCPs and highlighted nurses and pharmacists as important resources who could be consulted. “Within the VA, advanced practice providers and clinical pharmacy specialists have full scope of practice authority, and research indicates that interprofessional care models can lead to greater deprescribing,” they advised.
“Incorporating patient-directed educational strategies can increase the clinical uptake of deprescribing,” the study concluded. “With healthcare increasingly prioritizing patient-centered delivery models, this intervention can be easily disseminated to have timely impact on quality, safety and satisfaction among patients, clinicians, and health care systems.”
- Jones KF, Stolzmann K, Wormwood J, Pendergast J, Miller CJ, Still M, Bokhour BG, Hanlon J, Simon SR, Rosen AK, Linsky AM. Patient-Directed Education to Promote Deprescribing: A Nonrandomized Clinical Trial. JAMA Intern Med. 2024 Sep 23:e244739. doi: 10.1001/jamainternmed.2024.4739. Epub ahead of print. PMID: 39312257; PMCID: PMC11420822
