Canadian Deprescribing Network Annual Report 2016 CaDeN ReCaD Canadian Deprescribing Réseau canadien Network pour la déprescription The Canadian Deprescribing Network is a group of health care leaders, clinicians, decision- makers, academic researchers and patient advocates working together to mobilize knowledge and promote the deprescribing of inappropriate medications in Canada. The Network’s key objectives are to: • Reduce harm by raising awareness and decreasing the use of inappropriate medications for seniors by 50% by 2020. • Promote health by ensuring access to safer drug and non-drug therapies. The Canadian Deprescribing Network is initially focusing on three classes of medications that should be considered for deprescribing in seniors: • Benzodiazepines; • Proton pump inhibitors; and • Long-acting sulfonylureas. What is Deprescribing? Deprescribing is the planned and supervised process of reducing or stopping medications that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden and harm, while maintaining or improving quality of life. Contact us and get involved: Annie Webb, Communications Director Canadian Deprescribing Network Centre de recherche de l’Institut Universitaire de gériatrie de Montréal 4565 chemin Queen-Mary, Montréal (Québec) H3W 1W5 Email: [email protected] @DeprescribeNet Website: deprescribing.org/caden/ The Annual Report is available on the website in French and English (printed copies available by request). 2 Contents 4 Message from Directors 5 Why Focus on Deprescribing? 9 The Network 14 Achievement Timeline 16 Public Awareness & Motivation 19 Health Care Provider Capacity 22 Policy-Maker Opportunities 24 Events & Networking 26 Partners & Collaborators 28 Network Representation 32 References 3 Message from Directors 2016 marks the launch of the Canadian each province to limit consumption. We also Deprescribing Network with a ground swell undertook a national population survey on of activity from leaders, individuals and deprescribing, and an international scan organizations across Canada who are of successful policy initiatives to reduce interested in deprescribing. Many joined benzodiazepine use. us in tackling the growing problem of over- We are grateful to our volunteers and medication, a problem highlighted in the staff, and to our enthusiastic collaborators Toronto Globe and Mail about “Seniors taking from the National Pensioners Federation, too many meds, it’s madness” (see article the Canadian Pharmaceutical Directors here: https://tgam.ca/1R5BXgo). It is with Forum, the Canadian Institute of Health great pride that we release our first annual Information, the Canadian Agency for Drugs report, showing the multi-level systems and Technologies in Health, the BC Shared approach that the Network recommends to Care Polypharmacy Group, the Canadian shift the way medications are being used and Foundation for Healthcare Improvement and overused in this country. Choosing Wisely Canada, among others. Funded by a Partnership for Health System We sincerely acknowledge Chris Power’s Improvement grant from the Canadian contribution, CEO of the Canadian Patient Institutes of Health Research and the Ministère Safety Institute, who delivered the keynote de la Santé et des Services sociaux du address at our 2016 annual meeting. Québec, our members rallied to put in place an Our deprescribing.org website hosted over action plan to curb the use of risky medications 67,000 visitors, and hundreds of individuals and increase access to non-pharmacological received our newsletters. A warm thank you therapies. Our public awareness subcommittee to the journalists and radio reporters from began by creating an inventory of user- across Canada and the U.S. who are helping friendly resources to determine if medications us showcase the budding efforts and stories can be stopped, and how this might be of the Canadian Deprescribing Network. done. The health care provider awareness subcommittee compiled resources to help clinicians understand and facilitate approaches to deprescribing and posted them on our deprescribing.org website. They also reached out to health care educators across Canada Dr. Cara Tannenbaum, MD, MSc to encourage them to include information Director, Canadian Deprescribing Network about the risks of medication use in older adults and approaches to deprescribing in their educational programming. The policy subcommittee evaluated three drug Dr. James Silvius, MD, BA (Oxon) indicators, and scanned current policies in Co-Director, Canadian Deprescribing Network 4 Why Focus on Deprescribing? anadians are living longer with chronic Polypharmacy refers to the use of five or disease, with one in four Canadian more medications, taking more medications Cseniors suffering from three or more than clinically indicated, or use of medications chronic conditions, such as diabetes, high where harm outweighs benefit. blood pressure, arthritis, osteoporosis, cancer, Taking medications may be necessary for chronic pain and mental illness (CIHI 2014). health, improving symptoms or prolonging life The majority of Canadian seniors with chronic expectancy. However, as we get older, the conditions are able to lead meaningful benefits and risks of medication may change. lives with the help of safe and effective With age, some medications become prescription medications. As the number unnecessary or even harmful because of chronic diseases increase with age, of short-term or long-term side effects, so do prescriptions. Seniors with three or drug-drug interactions, and drug-related more chronic conditions take an average hospitalizations. of six different medications (CIHI 2014). How many prescription medications are Canadian seniors taking? 2 out of 3 Canadians over 1 out of 4 Canadians over the age of 65 take at least the age of 65 take at least 5 different prescription 10 different prescription medications. medications. Seniors taking ≥10 medications 66% 27% 20% of seniors age 65 to 74 ≥ 5 dierent 32% of seniors age 75 to 84 medications 39% of seniors age 85+ (CIHI 2014) Why Focus on Deprescribing? 5 Unnecessary or Potentially Harmful Medications Seniors are most at risk, as age-related changes affect how the body handles and responds to medication – making them more sensitive to exaggerated drug effects as they get older. Canadian seniors who take at least one inappropriate medication 47% 42% Some medications may be 39% unnecessary, potentially 31% inappropriate and even harmful to seniors. These medications, compiled on the Beers criteria list, are known to increase the risk of over 65 over 85 adverse effects. years old years old (Morgan et al. 2016; 2013 CIHI data) Adverse Effects Risk of Drug-Drug Interactions Adverse effects of medication may include side effects, drug 8-fold interactions, falls, fractures, greater risk memory problems and risk of death. Older women are typically more of susceptible to adverse effects 4-fold medications and more likely to be greater risk prescribed risky medication. This is because women have a longer average life expectancy than men, suffer from more chronic conditions Low risk and typically take more medication. Female biology and physiology also increase the risk of harmful effects 2 5-7 8-10 of medication. Number of medications (Johnell and Klarin 2007) 6 Cost of Inappropriate Medications for Seniors Medications in general are costly. Inappropriate medications raise greater concern, because of the added indirect costs associated with drug harms and hospitalizations. Cost of commonly prescribed potentially inappropriate medications among Canadian seniors: $250 million $97 million Proton-pump inhibitors Antipsychotics Increased risk of fractures, memory Increased risk of memory and problems, pneumonia, Clostridium concentration problems, falls, fractures, difficile infections and diarrhea, kidney stroke, dizziness, confusion, diabetes disease, and low levels of magnesium and weight gain. and vitamin B12 in the blood. (CIHI 2015) $14 million $135 million Sulfonylurea diabetes pill Benzodiazepines glyburide Increased risk of cognitive impairment, delirium, falls, fractures Higher risk of hypoglycemia causing and motor vehicle accidents. dizziness, falls, fractures and confusion. (Morgan et al. 2013) Total costs of inappropriate medication among Canadian seniors $419 million $1.4 billion Canadians spend $419M per year Canadians spend $1.4B per year in on potentially harmful prescription health care costs to treat harmful medications. This does not include effects from medications, including hospital costs. fainting, falls, fractures and hospitalizations. (Morgan et al. 2016; 2013 CIHI data) Why Focus on Deprescribing? 7 Falls, Fractures and Seniors 9% of all emergency department visits Falls are the leading cause of injury hospitalizations for seniors across the country, contributing to 9% of all emergency department visits (CIHI 2011). Certain inappropriate medications, such as benzodiazepines, antipsychotics and long-acting sulfonylureas, can increase the risk of falls by 50% because they cause side effects like 50% concentration and balance problems, or dizziness. Seniors living in the community that are institutionalized within 20-30% 30% a year following a hip Hip fracture patients that fracture in Canada. die within 1 year after the (Morin et al. 2012) fracture. (Khong et al. 2012) Cost of a Hip Fracture Annual direct attributable health care $1.1 billion costs for hip fractures in Canada. $36,929 $39,479 for a woman for a man (Nikitovic