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Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation

  • Marcia C. MeccaEmail author
  • John M. Thomas
  • Kristina M. Niehoff
  • Anne Hyson
  • Sean M. Jeffery
  • John Sellinger
  • Adam P. Mecca
  • Peter H. Van Ness
  • Terri R. Fried
  • Rebecca Brienza
Original Research

Abstract

Background

Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited.

Objective

The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents’ knowledge of polypharmacy and perceptions of this interprofessional education intervention.

Design

A prospective cohort study with an internal comparison group.

Participants

IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications.

Intervention

IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model.

Main Measures

We assessed residents’ performance on a pre-post knowledge test, residents’ qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased.

Key Results

The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus − 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12–19), and a median of 2 medications (IQR 1–3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency.

Conclusions

Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents’ knowledge and skills, and is perceived by residents to influence their practice outside the program.

KEY WORDS

interprofessional education geriatrics polypharmacy medication management primary care 

Notes

Acknowledgments

The authors would like to acknowledge and thank Elizabeth Armstrong, Ph.D. and the Harvard Macy Institute, as well as Lauretta Grau, PhD, for her skillful assistance with the coding of manuscripts, and Destiny Printz, for her skillful conducting of focus group interviews.

Funders

This work was supported in part by the Veteran Affairs Office of Academic Affiliations (COEPCE), VA Connecticut Healthcare System, John A. Hartford Foundation (Center of Excellence Geriatric Scholar Award), the Yale Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA), the National Institute of Mental Health (5R25MH071584-07), and an award from Health Resources and Services Administration Geriatric Workforce Enhancement Program to Yale University School of Medicine (U1QHP28745).

Compliance with Ethical Standards

This study was approved by the Human Subjects Committee at Veterans Affairs Connecticut. Waiver of informed consent was granted and no participants received payment.

Conflict of Interest

Dr. Jeffery is a consultant for CVS Caremark. All remaining authors declare that they do not have a conflict of interest.

Disclaimer

This material is the result of work supported with resources and the use of facilities at the VA Connecticut. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Marcia C. Mecca
    • 1
    • 2
    • 3
    Email author
  • John M. Thomas
    • 1
    • 2
    • 4
  • Kristina M. Niehoff
    • 5
    • 6
  • Anne Hyson
    • 1
  • Sean M. Jeffery
    • 6
    • 7
  • John Sellinger
    • 2
    • 8
  • Adam P. Mecca
    • 9
  • Peter H. Van Ness
    • 1
    • 10
  • Terri R. Fried
    • 1
    • 6
    • 10
  • Rebecca Brienza
    • 1
    • 2
  1. 1.Department of MedicineYale School of MedicineNew HavenUSA
  2. 2.Center of Excellence in Primary Care Education, Veterans Affairs Connecticut Healthcare SystemWest HavenUSA
  3. 3.Clinical Epidemiology Research Center, VA Connecticut Healthcare SystemWest HavenUSA
  4. 4.Dominican House of Studies, Pontifical Faculty of the Immaculate ConceptionWashingtonUSA
  5. 5.Vanderbilt University Medical CenterNashvilleUSA
  6. 6.Integrated Care Partners, Hartford HealthCare GroupWethersfieldUSA
  7. 7.University of Connecticut School of PharmacyStorrsUSA
  8. 8.Department of PsychologyVeterans Affairs Connecticut Healthcare SystemWest HavenUSA
  9. 9.Department of PsychiatryYale School of MedicineNew HavenUSA
  10. 10.Program on AgingYale School of MedicineNew HavenUSA

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