An interview with Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE, a palliative care pharmacist at University of Pittsburgh, School of Pharmacy by Winnie Ho, Program Coordinator
Overview: This intervention is taking place in the University of Pittsburgh Medical Center (UPMC) Senior Communities in Pittsburgh, Pennsylvania. Dr. Pruskowski's work is funded by The Beckwith Institute.
NaRCAD: Hi Jennifer, thank you for taking the time to speak with us today! You are breaking new ground on a deprescribing academic detailing project in Pittsburgh. What role does deprescribing play in improving health outcomes in nursing homes?
Jennifer: Deprescribing is the identification and discontinuation of potentially unnecessary or inappropriate medications. What I really love about deprescribing is that it’s really patient-centered.
For example, one medication class might be appropriate for one patient, but maybe not for the next. Within the UPMC Senior Communities, I have developed, implemented, and evaluated a clinical pharmacy-driven deprescribing initiative named the DE-PHARM Project, which stands for the "Discussion to Ensure the Patient-centered, Health-focused, Prognosis-appropriate and Rational Medication regimen". Say that 5 times fast!
This project allows pharmacists within the nursing home setting to review medication regimens and conduct conversations with nursing home residents, their families, and their caregivers. Deprescribing allows us to rebalance the equation when there may be medication overload, and helps us to reduce the burden on our patients.
NaRCAD: What are unique factors when approaching deprescribing work in nursing homes?
Jennifer: While a lot of patients outside of the nursing home are complex, the nursing home population is one of the most obvious and at-need, due to their reduced functional status and their need for additional services. Nursing home residents also tend to receive their care, essentially, from one provider. So, it’s very conducive for deprescribing, and it allows us as an academic detailing program to overcome one of the main barriers to deprescribing, which is tracking down and contacting potentially numerous prescribers.
NaRCAD: That's a pretty common barrier, to track down and identify the multiple providers that are supporting the patient.
Jennifer: Absolutely. The other thing to consider is that there are already regulations in place within a nursing home setting that encourages deprescribing. Every nursing home that receives Medicare or Medicaid has certain regulations to follow, which is basically all of them. For example, since the mid 2000’s, there’s been verbiage around ‘gradual dose reduction’ for anti-psychotics, and then in the last 5 to 7 years, this was expanded to antimicrobials as well to try to curb growing antibiotic resistance.
Nursing homes are built for deprescribing, in the sense that these medications are continuously monitored and every quarter, they need to justify to CMS why someone is on a medication at a certain dose.
However, what gets challenging is integrating care goals, functional status, patient perspectives, and evidence-based literature into deprescribing. Nursing home settings often times have a comfort-focused treatment plan. The medications that I tend to focus on when encouraging deprescribing may not be the same as other detailers. For example, many detailers are working on opioid-related campaigns. Opioids are crucial for deprescribing, but if you think of a patient who is closer to the end of life, opioids are typically not what we target because the medication tends to align with their treatment plan and goals.
NaRCAD: That’s a really interesting and complicated situation. What are some of the other challenges you’re facing with approaching deprescribing in nursing homes?
Jennifer: One of the big challenges is that no studies have been done about the initiation of certain medications in nursing home residents. Most clinical trials are also done in healthier, younger adults. We don’t have the most literature to guide a lot of what we do, and it’s critical because our prescribing goals are going to be different for the nursing home population as compared to the general population.
NaRCAD: This can often be a challenge when initiating an academic detailing campaign in a field that may not have as many other detailers. One of the foundations of academic detailing is the dissemination of evidence based information, but as you mention, there are not as many resources and studies in the work you’re about to partake in.
As you and your team begin to initiate your program, how do you plan on approaching this paradox?
Jennifer: So, the first thing that we’re doing is determining the medication that we’re going to target. We’re taking a look at prescribing cultures within the nursing homes that we’re targeting, and our working group is looking at what medication regimens are potentially inappropriate, or deprescribing eligible.
There is an evidence-based algorithm that we utilize for our intervention based on what medication class we will target from deprescribing.org, run by Barb Farrell, a friend and colleague of mine in the Canadian Deprescribing Research Network. So for some medications, such as proton pump inhibitors or histamine blockers, there are resources that have been created.
However, as we do the groundwork for our program, we could potentially find ourselves targeting a medication class that doesn’t have a lot of evidence-based literature around it, and then that will be both the challenging and fun part of developing verbiage and guidelines around that.
NaRCAD: Someone’s always got to do it first! It can be difficult getting programs started, and we are very lucky to have a growing population of people who are interested in integrating academic detailing into their programs.
As you’re reflecting and planning for the future, what would be important for someone else in your shoes to know about starting a new program?
Jennifer: The most important part is really thinking through the needs assessment. We know that there is a problem, and now it’s about identifying the specific issues and critically thinking through a solution. We will really need to understand the prescribing behaviors that exist in our nursing homes. Much of the prescribing culture there is based off inertia, extrapolation, and people doing their best to adapt important regimens from information that doesn’t directly address their unique situations with nursing home residents.
We are trying to see if, for example, our providers are prescribing certain medications because they see this problem a lot in other populations they work with, or if they are working off of knowledge that has not been updated in many, many years. These would be two very different academic detailing interventions.
NaRCAD: And finally, as we begin a brand-new decade in 2020, what would you say to anyone else looking to consider academic detailing?
Jennifer: Jump in! Academic detailing is a proven intervention to effectively disseminate evidence-based literature. I would say that as much as academic detailing can feel like a one way street – as a detailer coming to give a provider information – it really is more of a two-way street than people think. I think in the small amount of time that I’ve done this, I feel like I’ve actually gotten more information from our prescribers than I feel like I’m giving to them at the end of the day.
NaRCAD: A fantastic note to end on. Thank you so much for taking the time to speak to us, and we wish you and your team continued success in 2020!
Dr. Pruskowski received her PharmD from Wilkes University in Wilkes Barre, Pennsylvania. She then completed a Post-Graduate Year One Pharmacy Practice and Post-Graduate Year Two Geriatric Residency from the Williams Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina, as well as an Interprofessional Palliative Care Fellowship at the James J. Peters Veterans Affairs Medical Center in Bronx, New York.
Dr. Pruskowski is a Board Certified Pharmacotherapy Specialist, a Certified Geriatric Pharmacist, and a Certified Pain Educator, and has received specialized training in pain management from the American Society of Consultant Pharmacists and the American Society of Health-System Pharmacists. Her clinical practice site is the University of Pittsburgh Medical Center (UPMC) Palliative Supportive Institute (PSI) as the Palliative Care Clinical Pharmacy Specialist.
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