Building Block #2: Sustainable polypharmacy model (TAPER): scale and spread

Generally speaking, our systems of medical care support healthcare providers in adding new medications to a patient’s regimen. However, there are few if any systems in place for reducing medications to reduce the risks of inappropriate polypharmacy, and many attempts to address this issue have shown disappointing results. There is a large body of evidence showing that polypharmacy puts patients at risk—so why isn’t preventing it more common? How can reducing medications become an intrinsic part of person-focused care?

In order to build a pathway for polypharmacy prevention that would work in everyday practice, we needed to understand the problem of polypharmacy, as well as the barriers to addressing this in clinical practice.

Barriers to Addressing Polypharmacy

Despite the known risks of polypharmacy, reducing polypharmacy (a process often called deprescribing) has been found to be challenging for some healthcare providers. We identified many barriers and enablers to deprescribing faced by physicians including:

Lack of available clinical information and context (i.e. why patients were put on medications to begin with)
Fear of negative health outcomes following deprescribing
Reluctance to alter course of medications prescribed by other physicians, especially specialists
Lack of decision support systems
Lack of appropriate continuity of care
Lack of time, resources, and funding for deprescribing

We also found enablers of deprescribing included:

Working with pharmacists (and/or other clinicians) using a multidisciplinary, integrated approach
Better communication across the health system, and increased levels of continuity of care
Readily available guidance and resources to support processes of deprescribing

Why Focus on Primary Care?

Most care for patients with chronic conditions and multimorbidity is provided and coordinated through primary care, as is most long-term prescribing. Primary care is the setting where care of multiple conditions is integrated, and prioritized. Given this, and the sheer scale of the problem of polypharmacy this setting makes sense. The longitudinal relationship between primary care providers and their patients enables the surfacing of patients priorities and context. It also makes sense that addressing polypharmacy, which requires a generalist approach to care, is well suited to the primary care clinical approach.

Evidence for Reducing Polypharmacy and Developing the TAPER Model

There have been many systematic reviews of interventions to address polypharmacy, including one conducted in 2020 by the TAPER team, which showed that interventions to reduce polypharmacy can help improve mobility outcomes in older adults.

In order to build the TAPER model, we did 3 pieces of work:

We conducted a “review of reviews” to try to identify any key elements for success

One of the key findings in our review is that few studies described the “theoretical basis” of their approach or pathway – i.e., the model and basis for the model which describes the mechanisms by which it would be likely to work. This seems critical—many interventions to reduce polypharmacy have been trialed, but have been disappointing in their impact on patient outcomes or practice. Which led to the second key piece…

We worked bottom-up to develop this kind of theoretical model for a TAPER pathway

What would a successful model that addressed these barriers, used the known enablers, and crucially, was feasible to deliver to the population in as part of routine care look like? In a 2023 paper published by the TAPER team, we describe the development process of an operationalised clinical pathway to reduce polypharmacy by linking it to the underpinning care models, mapping the known barriers, and depicting the facilitators that were built into the intervention.

Talking to patients

We asked patients what a model of care looked like when deprescribing went well. In 2019, the TAPER team published an important qualitative study, candidly titled ‘I think this medication actually killed my wife’. This study was conducted to better understand how patient and family members’ perspectives and priorities are incorporated into shared decision-making conversations surrounding medication use. Results from this study indicated that patients often felt a disconnect between patient (or caregiver) and physician preferences, priorities and rationales for treatment, and felt as though their voices were not being heard. They highlighted the fact that very often, person-focused care and shared decision-making within the context of multimorbidity and polypharmacy, is not optimally achieved. The key aspects they highlighted for success of a deprescribing process included the ability of a process to elicit, record, and integrate patient expertise/experience, preferences and priorities about medications. This creates an ongoing space for patients or caregivers to participate in shared decision-making. Having such a space may be particularly important for patients who may have a different level of privilege (and power), health literacy or understanding of the healthcare system. This ‘space’ gives permission for bringing one’s expertise to the conversation and may reduce the perceived burden of having to negotiate power or making decisions around medications. What patients were describing in our study is person focused care, which is discussed below.

These three key pieces of work helped lay the foundation for the design of the TAPER structured clinical pathway. Patients are encouraged to consider themselves as an expert in their own medical care and share their lived experience with medication use, as well as to share their own therapeutic goals and symptom priorities with their care team in order to develop a plan for optimizing medication together.

Person-Focused Care

Person-focused care is the integration of the knowledge of the persons values preferences and priorities and unique medical circumstances over time. It takes a holistic approach to healthcare, seeing each individual as an expert and active participant within their own circle of care, and focuses on health outcomes, goals and treatments that align with a patient’s unique preferences and priorities.

What patients described they needed aligned perfectly with what the evidence shows—namely, that one of the key mechanisms by which primary care improves patient health outcomes (e.g., morbidity, mortality, and quality of life) is through person-focused care.

How Can We Incorporate Person-Focused Care into a Process for Deprescribing?

To begin, we took a critical look at how primary care for patients with multiple conditions and risk factors (i.e. multimorbidity) often follows a single disease model, and how unwavering adherence to clinical practice guidelines can burden patients with overly complicated, and potentially harmful medication regimens. Treating patients as a collection of their single diseases doesn’t work, but viewing patients as a collection of their medications is also problematic. In 2018 the International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP) released a position statement and 10 recommendations for action, describing the issues with both disease based and drug based approaches and recommended including implicit strategies that take patient preferences into consideration.

We looked for existing tools that included a person-focused centred approach in an explicit way and incorporated patient priorities into care that would be suitable for use in patients with multimorbidity and polypharmacy. A systematic review conducted in 2016 could only identify one study that elicited patient preference in the context of multimorbidity.

Evidence Support Tools—Putting it All Together

Deprescribing for complex patients with multimorbidity can be challenging for clinicians. Having support and tools (such as deprescribing guidelines, computer-based decision support tools, and clinical evidence) available can help make the deprescribing process more streamlined and efficient, as well as boosting a clinician’s confidence throughout the process.

Another key aspect of the TAPER model is having the most up-to-date evidence, tools, and resources available to support clinicians in deprescribing made as easily accessible as possible—all in one place, at the click of a button. PIMS Plus, a website compiling the latest and most up-to-date medication safety and deprescribing resources to help clinicians and patients manage their medications safely, is one recent example that was developed by the TAPER team in conjunction with the American Society of Consultant Pharmacists. TaperMD, the electronic pathway used within the TAPER intervention, is another tool designed to help facilitate deprescribing in clinical practice.

TaperMD

TaperMD is an electronic pathway that maps the TAPER model, created by our team with the help of a team of developers, and incorporating feedback and input from clinicians, patients and research experts. It was created to map the parts of the model designed to overcome barriers to deprescribing and support feasiblity in routine practice.

The TaperMD tool integrates each element of the TAPER pathway: patient priorities and experience; clinical support; and the most up-to-date evidence on deprescribing, medication management, and clinical pharmacology. Perhaps most importantly, TaperMD helps center a patient’s priorities of care and treatment, by eliciting these from patients first (along with other important clinical information relating to prescribing, such as renal function, history of falls, etc.), and having them visible throughout the shared decision-making process.

It also includes an automatic machine medication screen, where medications are automatically screened for anticholinergic burden, potential for harmful interactions, important black box warnings, and potential inappropriateness. The TaperMD tool integrates the most current medication-related evidence, guidelines—and even some custom-built tools— so that clinicians have as much information as possible available directly at their fingertips.

Finally, TaperMD allows space for all members of the care team to create, access, edit and monitor a patient’s agreed-upon deprescribing plan, as well as providing a dedicated channel of communication between members of the TAPER team for deprescribing conversations to take place.

The TAPER Model

The TAPER Model is the end result of integrating all of the above evidence, tools, and resources into one operationalized clinical pathway consisting of 3 steps:

Patient Input – patients and providers discuss their priorities for care, treatment and medication use, as well as detailing any functional goals, symptoms and side effects they may be experiencing.
Development of the plan using TaperMD – the patient’s medications are input into TaperMD, where they undergo a machine screen to help identify potential medication-related issues. The patient also undergoes a thorough medication review and with the TAPER pharmacist, and both work together to develop a plan for deprescribing that aligns with the patient’s preferences.
Trial of the deprescribing plan using a “pause and monitor” approach – after the initial plan is developed, patients will consult with their primary care provider. Together, they will go over the plan and decide how the plan will be implemented, and how the patient will be monitored during the trial period. TaperMD allows for asynchronous communication between the pharmacist and prescriber, so that both clinicians can efficiently update the plan and communicate with each other as necessary during the pause and monitor period.