The Drug Burden Index Intervention Bundle Involving A Stewardship Pharmacist To Facilitate Deprescribing Of Anticholinergic And Sedative Drugs

• By: MASNOON, Nashwa (Australia)
• Co-author(s): Dr Nashwa Masnoon (Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Ms Sarita Lo (Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Dr Kenji Fujita (Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  Professor Sarah Hilmer (Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia)
  
• Abstract:

  Background: The Drug Burden Index (DBI) measures exposure to anticholinergic and sedative drugs, which are commonly associated with harm in older adults. We piloted a novel in-hospital intervention bundle including the DBI in electronic Medical Records (eMRs) and a stewardship pharmacist, to facilitate deprescribing of sedatives and anticholinergics in older adults.
  Purpose: Following implementation of the bundle, to explore i) uptake of the stewardship pharmacist’s deprescribing recommendations by the hospital medical team, ii) hospital clinician experiences of using the bundle, and iii) patient, carer and General Practitioner’s (GP’s) experiences of in-hospital medication review and deprescribing.
  Method: Hospital clinicians in the target services of Geriatric Medicine and General Medicine at the Royal North Shore Hospital, Australia were educated on the bundle during the study period of July 13, 2021 to October 31, 2021. To increase uptake of the bundle, the stewardship pharmacist reviewed eMRs of target service patients aged≥75 years with a DBI score>0 and made deprescribing recommendations to the medical team. Semi-structured interviews were conducted with hospital clinicians, patients and carers to understand stakeholder experiences. Hospital clinicians in target services were eligible. Patients aged≥75 years with high-DBI (DBI≥1) in the target services, and their carers were eligible. Surveys were distributed to consenting patients’ GPs. Uptake of the stewardship pharmacist’s recommendations and survey responses were summarised using descriptive statistics. Qualitative interview data was thematically analysed. Clinician interviews were mapped to domains from the Human Organisation Technology-fit Framework. Patient interviews were mapped to the National Health Service Patient Experience Framework.
  Results: Out of the 256 patients reviewed, the stewardship pharmacist made 170 recommendations for 117 patients, most commonly due to falls (n=82 recommendations, 48.2%). The medical team agreed with 141 recommendations (82.9%) for 95 patients (81.2%) and actioned 115 recommendations for 80 patients. The 115 actioned recommendations resulted in 125 changes, most commonly antidepressants and opioids, with 44 changes to the inpatient drug chart and 81 changes recommended post-discharge in the Discharge Summary. Eight hospital clinicians comprising of medical consultants, registrars, interns and ward pharmacists completed the interviews and mainly reported themes around the subdomain of system use. Seven patients and two carers completed the interviews and mainly reported themes around information, communication and education. Four GPs completed the survey. Hospital clinicians indicated that the bundle supported in-hospital communication such as facilitating medication review during ward rounds but reported challenges such as heavy workload, with suggestions to further integrate the bundle into existing workflows. Most patients with deprescribing reported feeling better or no different. Patients, carers and all surveyed GPs described poor communication from hospital clinicians regarding in-hospital medication changes and rationale behind changes.
  Conclusion: This study demonstrates a novel role which pharmacists can undertake utilising their clinical skills and a decision support tool such as the DBI, to optimise medications in older adults. The intervention bundle was well accepted by hospital clinicians but requires further integration into existing workflows for sustainability. Future studies should aim to facilitate communication of in-hospital medication changes and rationale for changes with all medication management stakeholders.