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Patient Education and Pharmacist Consultation Influence on Nonbenzodiazepine Sedative Medication Deprescribing Success for Older Adults

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Patient Education and Pharmacist Consultation Influence on Nonbenzodiazepine Sedative Medication Deprescribing Success for Older Adults ORIGINAL RESEARCH & CONTRIBUTIONS Patient Education and Pharmacist Consultation Influence on Nonbenzodiazepine Sedative Medication Deprescribing Success for Older Adults Jennifer L Kuntz, PhD1; Louis Kouch, PharmD2; Daniel Christian, PharmD2; Weiming Hu, MS3; Preston L Peterson, MD4 Perm J 2019;23:18-161 E-pub: 12/27/2018 https://doi.org/10.7812/TPP/18-161 ABSTRACT Emerging scientific literature emphasizes the need for discon- Introduction: Use of nonbenzodiazepine sedative hypnotics or tinuation, or deprescribing, of drugs when existing or potential “Z-drugs”—including eszopiclone, zolpidem, or zaleplon—is dis- harms outweigh existing or potential benefits.8-13 However, the couraged for older adults; however, these medications commonly literature also acknowledges that discontinuing a medication may are prescribed to treat insomnia in this population. We evaluated the be just as difficult, if not more difficult, than starting a medication. impact of direct-to-patient education, with or without a pharmacist One approach to deprescribing that holds great promise is direct- consultation, on Z-drug discontinuation among Kaiser Permanente to-patient education, which provides information about medica- Northwest members age 64 years and older. tion use risks and empowers patients to initiate discussions with Methods: We randomized 150 patients to usual care (UC), educa- their prescribing clinician about medication discontinuation.14-16 tional information only, or educational information and pharmacist Kaiser Permanente Northwest (KPNW) piloted an intervention consultation. Patients age 64 years and older who received 2 to 3 that sought to encourage deprescribing of Z-drugs among KPNW Z-drug fills in 2016 were included. Logistic regression was used to patients 64 years of age and older. Patients were randomized to calculate odds of discontinuation at 6 months among patients who receive usual care (UC) or direct-to-patient education with or received either intervention, compared with those who received UC. without a pharmacist consultation. We examined the impact of Results: Patients who received education only and education these interventions on Z-drug discontinuation. plus pharmacist consultation were significantly more likely to dis- continue Z-drug use than those who received UC (28/50 of those METHODS who received education only and 27/49 of those who received In 2017, KPNW, an integrated health care delivery system serv- education plus consultation vs 13/50 patients who received UC). ing about 580,000 members in Northwest Oregon and Southwest After controlling for patient demographics, comorbidity, and Washington, conducted a pilot implementation of an interven- antianxiety and antidepressant medication use, patients who tion that used both direct-to-patient education and pharmacist received education only had greater odds of Z-drug discontinua- counseling to encourage deprescribing of Z-drugs among older tion than those in the UC group (adjusted odds ratio = 4.02, 95% adults. The intervention was implemented by the KPNW health confidence interval = 1.66-9.77). Patients who received education care system as a quality improvement initiative and delivered as and a pharmacist call also had greater odds of discontinuing use of part of UC; consequently, the KPNW institutional review board, these drugs than those in the UC group (adjusted odds ratio = 4.10, which reviewed and approved this research, granted a waiver of 95% confidence interval = 1.65-10.19). informed consent. Conclusion: Patients who received direct-to-patient education Patients were eligible for the deprescribing intervention if they with or without a pharmacist consultation were significantly more were at least age 64 years and received 2 or 3 prescription medica- likely to discontinue Z-drug use than patients receiving UC. Providing tion dispensings of a Z-drug—including eszopiclone, zolpidem, evidence-based information about Z-drug use is an effective and or zaleplon—during 2016. Members were excluded if they had low-resource method to encourage drug discontinuation. less than 6 months of Health Plan enrollment or if they received a quantity ≤ 6 doses. Members also were excluded if they received INTRODUCTION palliative or hospice care or resided in an assisted-living facility Adults age 64 years and older routinely are prescribed nonben- during the year before randomization. Members were not eligible zodiazepine sedative-hypnotics (“Z-drugs,” which include eszopi- clone, zolpidem, or zaleplon) for insomnia treatment despite a lack of evidence that demonstrates these medications improve sleep over the long term and a wealth of evidence that links long-term Author Affiliations use with falls, daytime sedation, cognitive impairment, decreased 1 The Center for Health Research, Portland, OR quality of life, dependence, and hospitalization.1-7 Contrary to this 2 Department of Clinical Pharmacy Services, Kaiser Permanente Northwest, Portland, OR evidence and American Geriatrics Society recommendations that 3 Northwest Data and Analysis Center, The Center for Health Research, Portland, OR discourage Z-drug use, older patients continue to receive these 4 Division of Continuing Care Services, Kaiser Permanente Northwest,Portland, OR medications for months, years, or even decades.4 Corresponding Author Jennifer L Kuntz, PhD ([email protected]) Keywords: aged, deprescribing, medication safety, nonbenzodiazepine sedatives, older adult patients, patient education, Z-drug The Permanente Journal • https://doi.org/10.7812/TPP/18-161 1 ORIGINAL RESEARCH & CONTRIBUTIONS Patient Education and Pharmacist Consultation Influence on Nonbenzodiazepine Sedative Medication Deprescribing Success for Older Adults if they had active cancer, severe mental illness or current use of Z-drugs during 6-month follow-up, defined as a patient not receiv- an antipsychotic medication, dementia, or evidence of substantial ing a Z-drug dispensing from a KPNW pharmacy during that time. cognitive impairment (defined as current use of a cholinesterase We assessed occurrence of secondary outcomes, which included inhibitor or memantine). hospitalization, outpatient face-to-face encounters, and urgent We randomized 150 total patients (50 patients per arm) to 1 of care and Emergency Department visits during the 6-month 3 study arms: 1) no intervention (UC); 2) an educational mailing follow-up. We also examined the number of Z-drug dispens- and prescriber letter (Ed); or 3) an educational mailing, prescriber ings during follow-up for patients who did not discontinue use. letter, and clinical pharmacist telephone counseling session (Ed+). Older adults randomized to the Ed or Ed+ study arms began re- Statistical Methods ceiving their intervention on January 1, 2017, and all follow-up We used KPNW EMR data to examine baseline characteristics was completed in September 2017. for patients in the UC and intervention arms. These characteristics The intervention was delivered as part of UC; however, because included demographic information such as age, sex, and race; the patients in the intervention arms received a signed letter from their occurrence of Charlson comorbid conditions during the year before Z-drug prescriber, some prescribers opted out of their patients the index date; the occurrence of insomnia or sleep disorders during receiving a letter with their signature. Patients whose prescribers the previous year; the use of psychotropic medications during the opted out were not eligible to receive the intervention. To accom- 90 days before the index date as identified through dispensings at plish this, prescribers received an electronic medical record (EMR)- KPNW outpatient pharmacies; and baseline health care utiliza- based message and had the option to opt out by responding within tion during the previous 180 days. Psychotropic drugs included 14 days. Four prescribers declined to participate because they were antianxiety medications (including benzodiazepines), antidepres- on an extended leave (1 prescriber) or they preferred to not use a sants, opioids, muscle relaxants, and anticonvulsants. We identified case management approach (3 prescribers). dispensings of medications using Medi-Span Generic Product Identifiers available in KPNW EMR pharmacy data. Baseline The Intervention health care utilization included hospitalization, outpatient face- The goal of this effort was to implement and test 2 forms of an to-face visits, telephone and email encounters, and urgent care and intervention that directly provided older KPNW patients who Emergency Department visits. chronically use Z-drugs with information about risks associated We identified potential imbalance in the study groups by exam- with Z-drug use and then engage them in shared decision making ining standardized differences for select baseline variables. Variables regarding discontinuation. Patients randomized to the Ed or Ed+ with a standardized difference exceeding 0.1 between the random- arms received a letter from their prescribing physician, an educa- ized groups were considered for inclusion as control variables. Se- tional brochure, and a quiz. Educational materials were developed lection of potential control variables was based on plausibility of a by a team of primary care and geriatric health care physicians, phar- relationship between the characteristic and Z-drug discontinuation macists, and researchers. Prescriber letter text explained the reason and the prevalence of the characteristic within the population. for the letter and
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