Deprescribing: Importing Innovations from Outside the US A27 and B27

Deprescribing: Importing Innovations from Outside the US A27 and B27

Introductions Karen Smethers, BS, PharmD, BCOP, National Clinical Pharmacy Integration Leader, The Resource Group, Ascension L. Hayley Burgess, Pharm.D., BCPP, CPPS, AVP, Clinical Pharmacy and Medication Safety, Clinical Services Group, HCA Maisha Draves, MD, MPH, Medical Director of Pharmacy, The Permanente Medical Group Lynn F. Hilario Deguzman, Pharm.D., Regional Clinical Operations Manager, Northern California, Kaiser Permanente Leslie Pelton, MPA, Senior Director, Innovation, Institute for Healthcare Improvement

Workshop Objectives After this presentation, participants will be able to: 1. Understand the barriers and enablers to implementing deprescribing 2. Begin to develop a plan for testing deprescribing in their own health system

International Innovations Network Case Study: Evidence Based Medication Deprescribing Innovation Case Study

The Innovation from Ottawa, Canada http://deprescribing.org/

Why Deprescribing?

Ascension: Why Deprescribing? Proton Pump Inhibitor Therapy: Improve safety and value for our patients (e.g. reduce side effects including pneumonia, Cdifficile) Opioid/Sedative Agents: Improve safety (e.g. reduce side effects including respiratory depression and falls) and help prevent opioid overdose

HCA: Why Deprescribing? Upon review of Skyline Medical Center data, we identified an opportunity to reduce our use of Proton Pump Inhibitors This was encourage by the weight of evidence that PPIs are a critical pharmacotherapy risk factor for: renal disorders, pneumonia, osteoporotic fractures, electrolyte deficiencies, Clostridium difficile infections, and mortality Additionally, use of proton pump inhibitor therapy in hospital settings can lead to inappropriate continuation of therapy during transition in levels of care

Kaiser Permanente: Why Deprescribing? Deprescribe diabetes/blood pressure medications in well-controlled elderly: reduce risks of hypoglycemia, hypotension, and related consequences. Less unnecessary medication burden means more independence for patients. Build internal systematic processes to ensure continued safe use of medications as our patients age. Share best practices!

Ascension

Theory of Change: PPI Driver 1 PPI: Reduce equivalent patient day by 50%; Opioid/Sedation: Reduce mg use by 20% When: by July 2018 Your aim - What - How much - By when Driver 2 Driver 3

Theory of Change: Opioid/Sedative Driver 1 PPI: Reduce equivalent patient day by 50%; Opioid/Sedation: Reduce mg use by 20% When: by July 2018 Your aim - What - How much - By when Driver 2 Driver 3

HCA

Theory of Change- HCA Identification of people (patients) receiving PPIs Our aim is: By June 30, 2018 on the 4th floor unit of Skyline Medical Center, a 233 bed facility, will have a 10% reduction of adjusted PPI days of therapy (PPI DOT/1000 patient days) following the IHI PPI deprescribing initiatives. Clinical Pharmacy And Physician Engagement Evidence based algorithm in development of standard and simplified deprescribing work aids Clinical champions to support deprescribing efforts Process Improvement Dashboards Leadership Directed By Data Clinical Storytelling Data monitoring by: Corporate, Division, and Facility Leaders

Change Idea- HCA Comprehensive step wise approach to decrease utilization of PPIs following the antimicrobial stewardship model Our service is primarily rooted in medication management programs PPI DEPRESCRIBING SERVICE PROCESS MEASURES Percent of evidence-based PPI indications Percent of accepted PPI deprescribing recommendations OUTCOMES MEASURE Percent of monthly adjusted PPI DOT BALANCING MEASURE Percent of monthly adjusted H2 Blocker DOT

Results: Process Measures- HCA Innovation Months May Jun Jul Aug Sep Oct PDSA Cycle Completion 2 4 10 20 25 10 Percent of accepted PPI deprescribing recommendations 60% 78% 100% 100% 100% 100%

Kaiser Permanente

Theory of Change Focus on multiple partnerships Big picture approach

KP: Partnerships Physician Champions Clinical Pharmacy Operations Continuum Care/Geriatrics Division of Research Pharmacy Drug Use Management Clinical Endorsements/Subject Matter Experts High Risk Medication Group Pharmacy Operations Pharmacy Quality Pharmacy Research Physician Outpatient Quality Compliance Health Education Physician Education Oversight Operational input Clinical input Long term research, predictive analytics Operational input Clinical input Clinical input Operational input Operational input Short term, focused research Clinical input Operational input Patient engagement trainings Provider engagement trainings

KP Theory of Change

KP Change Idea 1: Centralized resource

KP Change Idea 2: PDSAs on the front line Support staff outreach (technician, student) Lab reminders Triage follow-ups to pharmacists ~50 patients

KP Results: PDSAs on the front line Training support staff was simple, already crosstrained in MTM (leverage existing resource) Reduced administrative workload of pharmacists Developed triage algorithm for referral to pharmacists

Lessons Learned

Lessons Learned: What we learned Even in 2017, technology implementation moves slowly. Educating and communication to clinicians is key factor for success; do not wait on technology to begin testing Engaging well-established and respected physician champions to support the recommendations was key to our success Involve the caregiver early and often

What we learned does work Original Goal Reality Implementing PPI clinical pharmacy workflow rules Accessing for proper indication via clinical decision support screens during order entry Identification of patients receiving PPIs and ensure proper indication Run manual report to identify PPI patients on for the 4th floor Accessing for proper indication first done manually Identification of patients receiving PPIs and ensure proper indication

Your Turn and Our Sharing

Participant Worksheet

Deprescribing: Importing Innovations from Outside the US Ascension HCA Kaiser Permanente