Deprescribing admission medication at a UK teaching hospital; a report on quantity and nature of activity

Abstract

Background Deprescribing medication may be in response to an adverse clinical trigger (reactive) or if future gains are unlikely to outweigh future harms (proactive). A hospital admission may present an opportunity for deprescribing, however current practice is poorly understood. Objective To quantify and describe the nature of deprescribing in a UK teaching hospital. Method Prescribing and discontinuation data for admission medication from a hospital's electronic prescribing system were extracted over 4 weeks. The rationale for discontinuation of a random sample of 200 was determined using medical records. This informed categorisation of deprescribing activity by clinicians into 'proactive' or 'reactive'. Data were extrapolated to estimate the proportion of admission medications deprescribed and the proportion which were reactive and proactive. Results From 24,552 admission medicines, 977 discontinuations were recorded. Of the 200 discontinuations sampled for review, only 44 (22.0%) were confirmed deprescribing activities; categorised into 7 (15.9%) proactive and 37 (84.1%) reactive. Extrapolation yielded 0.6% (95% CI 0.5-0.7%) of all admission medications deprescribed. Conclusion Limited deprescribing activity, dominated by reactive behaviour was identified, suggesting prescribers require a clinical trigger to prompt deprescribing. There may be scope for increasing proactive deprescribing in hospital, however the extent to which this is feasible is unknown.

Role of nurses in supporting proactive deprescribing

“…The role of medicines in patient care is to treat acute disease, manage symptoms or prevent further disease; therefore, the focus of healthcare professionals has been on their initiation (Sinnott et al 2013, Anderson et al 2014. At present, discontinuing medicines is usually only considered when the patient is experiencing adverse drug events such as side effects (Anderson et al 2017, Scott et al 2018a. The British National Formulary (BNF) (2018) -the main reference source that informs medicinesrelated decisions by UK healthcare professionals -focuses primarily on why, when and how to start medicines, with limited information on why, when and how medicines should be discontinued.…”

Deprescribing: routine pharmacy practice or an exciting research opportunity?

“…Secondly, the deprescribing that we observed was overwhelmingly reactive . Proactive deprescribing is where the decision regarding continuation or cessation of therapy is less ‘black and white’; the medicine may or may not be effective, and the risk of harm in that patient may no longer be outweighed by the benefits . Proactive deprescribing is undoubtedly more difficult for practitioners to execute than reactive.…”

“…Firstly, around 50% of prescribed medication is potentially inappropriate and so the current 1% of deprescribing activity is clearly not adequately addressing the problem of potentially inappropriate prescribed medication. Secondly, the deprescribing that we observed was overwhelmingly reactive . Proactive deprescribing is where the decision regarding continuation or cessation of therapy is less ‘black and white’; the medicine may or may not be effective, and the risk of harm in that patient may no longer be outweighed by the benefits .…”

“…We agree that central to the pharmacist's role is reviewing medicines to identify those which require deprescribing. But this is usually in response to a clinical trigger, such as an adverse drug reaction . This deprescribing is termed ‘reactive’ and is relatively straightforward as it is both unethical and negligent to continue the medication.…”

“…Proactive deprescribing is undoubtedly more difficult for practitioners to execute than reactive. This is reflected in limited proactive deprescribing being observed in both the secondary care and primary care settings …”