Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy

Caitlin McIntyre, Rory McQuillan, Chaim Bell, Marisa Battistella
American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation 2017, 70 (5): 611-618

BACKGROUND: Polypharmacy in hemodialysis patients can result in adverse patient outcomes. Deprescribing tools can reduce polypharmacy, yet no method exists for an outpatient hemodialysis population.

DESIGN: Quality improvement study.

SETTING & PARTICIPANTS: 240 patients in a tertiary-care outpatient hemodialysis unit.

QUALITY IMPROVEMENT PLAN: We aimed to: (1) develop a deprescribing tool for target medications with poor evidence for efficacy and safety, (2) determine its effectiveness in decreasing polypharmacy, and (3) monitor patient safety and satisfaction.

OUTCOMES: The primary outcome was the proportion of target medications completely deprescribed after 4 weeks. Secondary outcomes were the proportion of target medications completely deprescribed after 6 months, average number of medications per patient before and after deprescription, and proportion of successful deprescriptions for each target medication.

MEASUREMENTS: Number of medications deprescribed at 4 weeks and 6 months. Patient safety and satisfaction were monitored using drug-specific monitoring parameters.

RESULTS: A deprescribing tool for specific medications was developed and implemented in the hemodialysis unit. 5 medication classes were selected: quinine, diuretics, α1 -blockers, proton pump inhibitors, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins). All 240 patients in the unit were screened using the deprescribing tool. There were 171 of 240 (71%) patients prescribed at least 1 of the 5 target medications, and after applying the tool, 35 of 40 (88%) eligible patients had the medications deprescribed. There were 31 of 40 (78%) target medications completely deprescribed. 6 months after the study, only 5 of 31 (16%) medications discontinued were represcribed. At the end of the study, 57% of patients were taking fewer medications than at baseline. No adverse events were observed.

LIMITATIONS: Single-center study that relied on patient self-reporting of medication use and adherence to our recommendations.

CONCLUSIONS: Deprescribing tools can be applied successfully in an outpatient hemodialysis unit to reduce polypharmacy while maintaining patient safety and satisfaction.

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