Combating Polypharmacy: A Deprescribing Tool within the VA

Combating Polypharmacy: A Deprescribing Tool within the VA
Abigail Sirek, PharmD, CentraCare - Paynesville

Background: Polypharmacy has been associated with many harmful patient outcomes, such as adverse effects, falls, and hospitalizations. Deprescribing, defined as the process of tapering, discontinuing, or consolidating inappropriate medications, is used to combat polypharmacy and reduce unfavorable outcomes. Comprehensive medication reviews (CMRs) may aid in identifying medications no longer indicated or appropriate for patients. Currently, there are tools to help identify potentially inappropriate medications (PIMs), such as the American Geriatric Society Beers Criteria, Screening Tool of Older Persons’ Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) Criteria, and Medication Appropriateness Index. Although helpful for identifying many PIMs, other medications may still be inappropriate for patients due to indication, comorbidities, or individualized patient goals. The Veterans Health Administration (VHA) developed and implemented a deprescribing tool in 2016 called VIONE, which stands for Vital, Important, Optional, Not indicated, and Every medication has a specific indication or diagnosis (Table 1). The VIONE tool was initially utilized for veterans enrolled in Geriatric and Extended Care Programs and the goal was to expand use to those receiving care through primary care Patient Aligned Care Teams (PACT). 

Purpose: To pilot the VIONE methodology to assist with deprescribing in a single Veteran Affairs (VA) primary care PACT. 

Study Design: This was a quality improvement project conducted at a VA primary care clinic in Lexington, Kentucky. The VIONE Risk Scorecard (Table 2) was used to identify the primary care PACT with the greatest number of veterans at high risk for polypharmacy within the investigators’ institution. Veterans within the pilot PACT that were deemed “high-risk” (having 15 or more active medications) were included in the study population. Patients with upcoming primary care appointments during the six-month study period were offered a CMR appointment with a Clinical Pharmacy Specialist (CPS). CMRs were completed via telephone or face-to-face prior to the primary care provider’s (PCP) appointment. Recommendations for deprescribing, utilizing the VIONE methodology, were documented for the PCP to review. After the PCP discussed recommendations with the CPS and patient, changes were implemented at the PCP appointment, including documentation of the VIONE medication discontinuation reasons. Data was electronically stored in a national dashboard. The sum-annualized cost avoidance by deprescribing medications was estimated using the following calculation:

[(Price/unit)*(Quantity dispensed)/(Days supply)]*(Days of medication avoided; max 365 days).

Results: Between September 1st, 2019 and March 1st, 2020,231 veterans were identified as high-risk for polypharmacy-related adverse events. Of the 231 veterans, 99 (42.9%) were contacted by PCP with or without CPS, resulting in 136 medications discontinued. On average, 1.37 medications were discontinued per veteran, leading to an annualized estimated cost avoidance of $21,904.80. During this six-month period, 20 CMRs were performed by a CPS with 90 recommendations identified for deprescribing and 38 recommendations implemented (42.2%). The most common reason for medication discontinuation was “not indicated/treatment complete,” and the most common medications discontinued were ranitidine, cyanocobalamin, cholecalciferol, and aspirin.  

Conclusion: VIONE methodology was successfully implemented in the primary care PACT setting. The use of this tool resulted in over one-third of veterans identified as high risk for polypharmacy decreasing their pill intake by at least one medication.

Key Point: Deprescribing tools, such as the VIONE risk scorecard and methodology, may be utilized to assist healthcare providers in identifying patients at high risk for polypharmacy and determining which medications would be most appropriate to modify or discontinue.  

Reference:

  1. Nelson MW, Downs TN, Puglisi GM, Simpkins BA, Collier AS. Use of a deprescribing tool in an interdisciplinary primary-care patient-aligned care team. Sr Care Pharm. 2022;37(1):34-43. doi:10.4140/TCP.n.2022.34 

Table 1. VIONE Methodology for Deprescribing Practices

 

Description

Suggested Action

V

Vital: Life-sustaining medications

Continue but monitor dosage, frequency, and adjust accordingly

I

Important: Important for quality of life, 

though not life sustaining cost-effective

Continue but use medication with least side effects and most cost effective

O

Optional: Consolidate medications

Seriously consider reducing or stopping

N

Not Indicated: Discontinue medications no longer appropriate for the patient given age and current health status

Stop and monitor the outcome after stopping the medication

E

Every Medication has a Specific Indication or Diagnosis: Why is the patient being prescribing this drug? If you don’t know, then you must find out

Stop, reduce, or change it. Always document changes

Table 2. VIONE Risk Scorecard

Criteria

Points

≥ 15 Active medications*

1

≥ 65 Years of age 

1

Care Assessment Need score ≥ 90 Percentile

1

≥ 2 Emergency department visits in the last year

1

Fall documentation in the last year

1

*Baseline Inclusion Criteria