Pharmacist-driven deprescribing initiative in primary care.

BACKGROUND: Polypharmacy, a broad term to describe the use of numerous and often unnecessary medications, has been connected to frailty, hospital admissions, falls, and even mortality. The Veterans Health Administration (VHA) developed the VIONE (vital, important, optional, not indicated, and every medication has an indication) dashboard to identify patients with polypharmacy and serve as a framework for deprescribing of medications across VHA facilities where it is used in a variety of practice settings by different disciplines. OBJECTIVE: This study aimed to describe the implementation of a pharmacist-led, system-wide, deprescribing initiative in the primary care setting. PRACTICE DESCRIPTION: Interdisciplinary education was provided through academic detailing. Subsequently, patients were identified for inclusion in the project using the VIONE dashboard focusing on those at highest risk of polypharmacy and moving down to the lowest risk. Interested patients underwent a medication reconciliation. A clinical pharmacist practitioner (CPP) then contacted the patient to discuss potential deprescribing options. Recommendations were relayed to the primary care provider (PCP) for final approval and communicated to the patient by the pharmacy team. PRACTICE INNOVATION: Primary care CPPs (n = 3) integrated deprescribing into their standard workload. This service was implemented in the primary care setting across an entire health care system consisting of 16 different primary care teams. EVALUATION METHODS: The initiative's impact was measured by the number of discontinued medications, the acceptance rate of recommendations by the PCP, the potential annualized cost avoidance, and the number of patients referred to CPP medication management clinics. RESULTS: Among 63 patients, a total of 352 medications were deprescribed resulting in a potential annualized cost avoidance of $184,221. The acceptance rate of discontinuation recommendations was 96.7%. Subsequently, 25.4% of patients were referred to pharmacist-led clinics for disease state management. CONCLUSION: Embedding deprescribing into standard CPP workflow within the primary care setting facilitated a way for polypharmacy reduction and allowed the expansion of pharmacy-led services at VA Butler Healthcare System.

Diabetes Care Network: A Novel Model to Disseminate Team-Based Diabetes Specialty Care in a Rural Population.

PURPOSE: The purpose of the study was to examine the impact of a novel approach to provide diabetes specialty team care to rural patients with type 2 diabetes (T2DM) on clinical outcomes and processes of care. METHODS: Diabetes Care Network (DCN) provides Veterans with T2DM and elevated A1C an initial 6-week period of remote self-management education and support and medication management by a centrally located team of diabetes specialists. Participants are then comanaged by remote liaisons embedded in rural primary care facilities for the remainder of the 12-month intervention. In this pre-post intervention study, 87 Veterans enrolled in DCN from 2 different clinical sites had baseline and 12-month postenrollment A1C, systolic blood pressure, weight, and LDL cholesterol levels collected and compared using paired t tests. RESULTS: Participants were mostly male and White with elevated baseline A1C. Participants from both sites had significant improvement in A1C over the 12-month intervention period compared to an increase in the 12 months prior to enrollment. There were also significant improvements in LDL and systolic blood pressure at 1 site, with no significant change in weight at either site. CONCLUSIONS: DCN participants had significant improvement in A1C after not meeting similar goals previously in a robust primary care setting. A technology-enabled collaborative partnership between centrally located diabetes care teams and local liaisons is a feasible approach to enhance access to diabetes specialty care for rural populations.