Eliminating Medication Overload: A National Action Plan JANUARY 2020 About the Lown Institute action plan The Lown Institute convened 22 experts in medication use and polypharmacy into a working group to develop Eliminating medication overload: A national action plan. From July 2018 to July 2019, the working group convened on monthly phone calls to develop this comprehensive action plan. The creation of this action plan, including research, analysis, and writing, was supported by the Gordon and Betty Moore Foundation. We are grateful to our GBMF program officers, Beth Metcalf and Julie Lawrence, without whose guidance and support this initiative would not have been possible. The Lown Institute is a nonprofit think tank advocating bold ideas for a just and caring system for health. www.lowninstitute.org. Eliminating Medication Overload: A National Action Plan Working Group on Medication Overload Judith Garber, writer Shannon Brownlee and Karen Kahn, editors The Lown Institute This work was supported by a grant from the Gordon and Betty Moore Foundation (#6954) Copyright © 2020 The Lown Institute, All Rights Reserved Suggested citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. Endorsing Organizations Geropsychiatric Nursing Collaborative International Group for Reducing Inappropropriate Medication Use & Polypharmacy (IGRIMUP) * The American Geriatrics Society (AGS) affirms the value of this document. Affirmation of value means that AGS supports the general principles in this document and believes it is of general benefit to its membership. Working group members Emily G. McDonald, MD, MSc Lown Institute project staff Assistant Professor of Medicine, Poppy Arford Shannon Brownlee, MSc, McGill University Health Centre Patient Advocate Senior Vice President Project lead and editor Cynthia Boyd, MD, MPH Joseph S. Ross, MD, MHS Professor of Medicine and of Public Health, Professor of Medicine, Vikas Saini, MD, President Johns Hopkins University Yale University Project advisor Co-Principal Investigator, U.S. Deprescribing Research Network James Rudolph, MD Judith Garber, MPP, Health Policy Professor of Medicine, Brown University and Communications Fellow Theresa Brown, BSN, RN, FAAN Writer, action plan University of Pittsburgh Nilay Shah, PhD Associate Professor of Health Services School of Nursing Julia Healey, Assistant of Programs Research, Mayo Clinic Faculty and Author and Operations Writer, issue briefs Alan Cassels Kristin Zimmerman, PharmD, Communications Director, BCACP, BCGP Carissa Fu, MSc, Director of Program Associate Professor, Therapeutics Initiative, Operations University of British Columbia Virginia Commonwealth University Project manager Megan Chock, MD, MPH Andrew Zullo, PharmD, ScM, PhD Aaron Toleos, Vice President Assistant Professor, Brown University Geriatric Medicine, Kaiser Permanente, of Communications Hawaii Communications lead Brandon Combs, MD Advisory committee members Associate Professor of Medicine, Anthony Barrueta, JD Consultants Senior Vice President, Government University of Colorado School of Medicine Karen Kahn Relations, Kaiser Permanente Editing and media relations Lynn Deguzman, PharmD, BCGP Regional Clinical Operations Manager, John Bulger, DO, MBA Nicole Caddell Kaiser Permanente, Northern California Chief Medical Officer, Geisinger Health Plan Designer, action plan and issue briefs Maisha Draves, MD, MPH John Devlin, PharmD, FCCM, FCCP Medical Director of Pharmacy, Professor of Pharmacy, The Permanente Medical Group Northeastern University Family Medicine Physician Donna Marie Fick, PhD, RN, FGSA, Gayle Banner Esposito FAAN Patient Safety Advocate, Professor and Director of the Center Mothers Against Medical Error of Geriatric Nursing Excellence, Penn State College of Nursing Helen Haskell, MA President, Mothers Against Medical Error Terry Fulmer, PhD, RN, FAAN President, the John A. Hartford Foundation Corinne M. Hohl, MD Associate Professor, Emergency Medicine, James F. Graumlich, MD University of British Columbia Governor, American College of Physicians Holly Holmes, MD, MS Leigh Purvis, MPA Division Director, Associate Professor, Director, Health Services Research, AARP Geriatric and Palliative Medicine, McGovern Medical School Gordon Schiff, MD Associate Director, Brigham and Women’s Todd C. Lee, MD, MPH Center for Patient Safety Research and Associate Professor of Medicine, Practice; Associate Professor of Medicine, McGill University Health Centre Harvard Medical School Sharon Levine, MD Michael Steinman, MD Board of Directors, School of Medicine, Professor of Medicine, Kaiser Permanente University of California, San Francisco Co-Principal Investigator, Amy Linsky, MD, MSc U.S. Deprescribing Research Network Assistant Professor of Medicine, Boston University; Physician, Johanna Trimble VA Boston Healthcare System Patient Champion, Patients for Patient Safety Canada James McCormack, BSc (Pharm), PharmD Jeff Williamson, MD, MHS Professor, Faculty of Pharmaceutical Chief of Geriatric Medicine and Professor Sciences, University of British Columbia of Internal Medicine and Epidemiology, Wake Forest School of Medicine Table of Contents 6 Introduction CATEGORY 1: 11 Implement prescription checkups CATEGORY 2: 24 Raise awareness about medication overload CATEGORY 3: 39 Improve information at the point of care CATEGORY 4: 52 Educate and train health professionals to reduce medication overload 60 CATEGORY 5: Reduce industry influence CONCLUSION: 71 What you can do now 74 Glossary, Appendices, and References Introduction Introduction Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. What is medication Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events (ADEs) and were hospitalized overload? 1 more than 2 million times due to ADEs. Medication overload is the use of multiple medications that pose a greater risk of harm These numbers point to an emerging threat: the epidemic of medication than benefit. There is no strict cutoff for when overload among older Americans. In a 2019 report, “Medication the number of medications becomes harmful, Overload: America’s Other Drug Problem,” the Lown Institute found that multiple medication use among older adults is widespread, growing, and but the more a person is taking, the greater their causes significant harm. More than 40 percent of older adults take five likelihood of experiencing harm, including serious, or more prescription medications a day, a 200 percent rise over the past even life-threatening adverse drug events. 20 years. When over-the-counter drugs and supplements are included, two-thirds of older Americans take five or more medications. Medication While drugs provide benefits to many people, taking multiple overload: Scope, medications (called “polypharmacy” in the scientific literature) also increases the risk of serious, even life-threatening side effects. Older harms, and people are especially vulnerable to delirium, internal bleeding, dementia, drivers and falling. Other ADEs can include strokes, heart attacks, infections, and death. For every additional medication, a person’s risk of suffering an ADE increases by 7-10 percent.2-4 Numerous forces and incentives in the U.S. health care system make it easy for clinicians to prescribe medications and difficult to scale back the dosage or deprescribe (stop a medication). Among the many drivers of medication overload, the Lown Institute’s report identified three overarching themes: 1. Both patients and clinicians are steeped in a culture of prescribing, which promotes a “pill for every ill.” Direct-to-consumer drug advertising, the increasing medicalization of normal aging, the hurried pace of medical care, and the urge among doctors and other clinicians to “do something” about medical conditions all contribute to the culture of prescribing. 2. Clinicians struggle to prescribe and deprescribe appropriately in the face of significant information and knowledge gaps. Medical education and training often lack sufficient discussion and skill building around appropriate prescribing and deprescribing. Moreover, clinical practice guidelines offer little information about how to guide prescribing for older patients with multiple chronic conditions or how to safely stop a drug.5,6 2. The U.S. has a highly fragmented health care system, which leads to individuals receiving prescriptions from many different providers in various care settings. Too often, no single clinician or team is coordinating care and keeping track of all of the medications a patient has been prescribed. 6 Eliminating Medication Overload: A National Action Plan | Lown Institute Introduction Every day, 750 older people living in the United States (age 65 and older) are hospitalized due to serious side effects from one or more medications. What is medication Over the last decade, older people sought medical treatment more than 35 million times for adverse drug events (ADEs) and were hospitalized overload? 1 more than 2 million times due to ADEs. Medication overload is the use of multiple medications that pose a greater risk of harm These numbers point to an emerging threat: the epidemic of medication than benefit. There is no strict cutoff for when overload among older Americans. In a 2019 report, “Medication the number of medications becomes harmful, Overload: America’s Other Drug