Amp up deprescribing? Sure, but docs and pharmacists need to learn to cooperate
Deprescribing is of great interest to healthcare professionals, but it's not always easy to tell other members of a healthcare team that you're stopping a treatment that you did not initiate yourself.
But patients seem open to it: A recent report on polypharmacy found that more than 70% of Quebeckers over the age of 65 said they would be willing to stop taking one or more medications if their family doctor told them that it was possible. This, even though Quebec is the province where adults over the age of 65 most embrace polypharmacy: One-third of them requested at least 10 separate medications in 2022.
“Professionals are motivated by deprescribing but are looking for tools to put it into practice,” said Camille Gagnon, pharmacist and assistant director of the the Canadian Medication Appropriateness and Deprescribing Network. “Deprescribing should be seen as part of the whole prescription cycle.”
Faced with an unrelentingly busy schedule, health professionals need efficient interdisciplinary communication to initiate deprescribing. But some lack the needed communication skills, said pharmacist Rachel Rouleau, associate researcher at the Vitam Centre for Sustainable Health Research and clinical professor at University of Laval in Quebec City. “The majority of professionals are very good clinically—they can and know how to prescribe and deprescribe. Where the problem lies instead is with interpersonal skills and good manners.”
It's essential to address the issue of deprescribing with pharmacists, doctors or other professionals with whom we work, Rouleau said. “In performing diagnoses we need allies, and the doctor must sometimes be able to rely on the pharmacist. There are issues around the patients we are going to target and how we are going to follow up with them. Talking will eliminate many difficulties in managing deprescribing.”
The pharmacist is at the heart of the machine, said clinical nurse Émilie Bortolussi-Courval, who worked on MedSecure—which is being integrated into EMRs. MedSecure is a later version of the deprescribing app MedSafer, developed by McGill Unversity's Dr. Emily McDonald and Dr. Todd C. Lee.
“Ultimately, the professional who receives all the prescriptions is the pharmacist, an expert in pharmacotherapy. They must be able to rally the interdisciplinary team and produce a report for the other professionals, even if they are not a prescriber. This is an excellent starting point,” said Bortolussi-Courval.
Know how to justify your recommendation or decision
Once the topic has been addressed, it is a matter of targeting patients and their medications. This is where MedSecure comes in. Bortolussi-Courval explains that medications that may be deprescribed can be classified into three categories:
- high risk of harmful side-effects: such as sleep aids, which allow you to fall asleep on average seven minutes faster than if you did not take them, but with degraded sleep quality and side-effects, such as drowsiness or falls
- potentially inappropriate: the risks and benefits of which must be assessed by the prescriber (proton pump inhibitors, for example)
- futile (no longer helping patient)
“This is the starting point for determining which drugs should be targeted and reviewed as a priority,” she said.
The ISBAR communication method
- Identification/identity: Identification of the caregiver (name, function) and the patient (name, diagnosis, reason for consultation)
- Situation: Medical diagnosis or current care context and precise description of the problem requiring the call
- Background: Significant personal or therapeutic history, treatments initiated, recent clinical and paraclinical observations
- Assessment: Current subjective and objective data obtained during the clinical examination
- Recommendation: Assessment report, with a request to the professional suggestion an intervention (in the case of the pharmacist) or declaration of intervention (in the case of the doctor)
Communication process
The next task is communicating the assessments to the prescriber—a sometimes delicate step. “We must avoid offending the professional integrity or caliber of the doctor, by saying that what they prescribed did not make sense, for example,” said Rouleau. “We can find more positive arguments to support our decision. We can rely on recent studies, new symptoms, the patient’s feelings, etc.”
Professionalism is also needed on the prescriber's part, said Gagnon: “Since the arrival of new clinical procedures in pharmacies, everything has been going very well. Pharmacists know what they are doing and could do much more in terms of deprescribing."
To best communicate these results, according to Bortolussi-Courvel, there is nothing better than a handwritten report, following the ISBAR (or SBAR) method. (See sidebar.)
'Better prescribing'
Rather than "deprescribing," Rouleau prefers to talk about "better prescribing," to anticipate the harmful effects of polypharmacy. "We shouldn't get to that point. We need to learn to evaluate medications as we go along, to be proactive when faced with complications or interactions." According to her, the ideal would be to review all medications with each prescription, especially in the presence of polypharmacy. "We shouldn't wait until the end of life and long-term care to take an interest in it." It is not only the patient who will benefit but also health professionals who have less less risk of drug interactions and less need for followup.
To best communicate these results, according to Bortolussi-Courvel, there is nothing better than a handwritten report, following the ISBAR (or SBAR) method.
Overcoming discomfort for the benefit of the patient
It can be challenging, for example, for a treating physician to communicate a deprescribing notice to a specialist. "The question of not wanting to encroach on her field of practice can arise," said Bortolussi-Courval. “But a medication may have become unnecessary.”
Gagnon gave the example of a patient going to a hospital emergency room. The clinician decided not to review or question the relevance of the sleeping pill he was taking since he was there for a short time for another acute issue. When the patient was discharged, his family doctor did not review or question the relevance of the medication, since the emergency room had left it in place. However, she explains, deprescribing interventions are useful at all patient touchpoints are often very well-received by family doctors and specialists.
