Adverse drug events occur frequently and cause substantial harm to patients. Even with these negative effects, medications with known or potential risks are often prescribed or continued despite lack of benefit. While efforts exist to prevent the initiation of medications with low likelihood of benefit to the patient, fewer attempts to reduce potentially inappropriate prescribing have been oriented towards discontinuation of a medication a patient is already taking. This de-implementation-based approach is known as deprescribing. Problems associated with overmedication have influenced many Choosing Wisely recommendations, an American Board of Internal Medicine Foundation effort to reduce unnecessary tests or treatments. Specifically, proton pump inhibitors (PPIs), a medicine used to reduce gastric acid, should be de-escalated (i.e., have the dose reduced) to the lowest dose necessary to provide relief from gastroesophageal reflux symptoms. Likewise, certain medicines used to treat diabetes, such as insulin or sulfonylureas, have higher risk of causing hypoglycemia (low blood sugar). Thus, the use of these medications in older or sicker adults should be limited. Despite these recommendations to reduce usage of PPIs, sulfonylureas, and insulin, there are many medication-, patient-, provider- and system-level barriers to deprescribing. Though many clinical interventions are aimed at the provider or health care system, patients have a key role in their health care and may play an important part in deprescribing. Although some believe providers have primary responsibility for initiating deprescribing, patient initiation of discontinuation conversations can effectively facilitate deprescribing. Others have successfully activated patients in non-VA settings and with mental health medications by providing EMPOWER (?Eliminating Medications through Patient Ownership of End Results?) brochures to promote deprescribing, but little is known about how these brochures may lead VA patients to initiate deprescribing discussions with their providers, particularly about treatment of chronic medical conditions. Therefore, we propose this pilot protocol of providing informational brochures about PPIs and sulfonylureas/insulin to VA primary care patients in preparation for a future hybrid type I implementation trial.
Aim 1 ? Assess the implementation outcomes of feasibility, acceptability, and appropriateness of a patient- activation informational brochure to facilitate deprescribing.
Aim 2 ? Examine the pre-post effect of a patient-activation intervention by: 2a: Calculating the frequency of discussions about medication discontinuation. 2b: Assessing the proportion of encounters in which target medications were discontinued or de-escalated.
For Aim 1, we will use post-visit Veteran interviews, as well as clinician/staff interviews and focus groups, to understand the perceptions and effects of the brochures, role in practice, and barriers and facilitators to implementation.
For Aim 2, we will calculate discussion frequency with data from Veteran interviews and chart review. We will compare pre-post target medication discontinuation and de-escalation rates. We hypothesize that the brochures will prompt increased deprescribing discussions, as well as de-escalation or deprescribing. Increasingly, VA and other health systems recognize the critical role of the patient as the ultimate end-user of health care and an essential participant in decision making. Stopping or reducing inappropriate medication has the potential to improve health care safety and efficiency by using fewer medicines and decreasing adverse drug events and their associated costly use of health care resources. Paring down medication regimens may also improve patients' adherence to remaining medications and increase quality of life. This study is supported by our Operational Partners, Pharmacy Benefits Management and the De-implementation Quality Enhancement Research Initiative. These connections will facilitate the dissemination of findings to engage the Veteran in efforts to improve the quality and safety of medication use within VA.

Public Health Relevance

While efforts exist to prevent the initiation of medications with low likelihood of benefit, fewer have targeted medication discontinuation, a de-implementation-based approach known as deprescribing. Some believe providers have primary responsibility for deprescribing, but patient initiation of discontinuation conversations can facilitate deprescribing. Evidence-based recommendations address overmedication and suggest re- evaluating continuation of proton pump inhibitors (PPIs), insulin and sulfonylureas. Medication-related informational brochures have activated patients in non-VA settings and, in VA, with mental health medications to promote deprescribing, but little is known about how VA patients may initiate deprescribing discussions, particularly for treatment of chronic medical conditions. This mixed methods pilot protocol seeks to understand how informational brochures about PPIs and sulfonylureas/insulin function in the VA population in order to build a foundation for a future implementation trial to improve safe medication use.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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VA Boston Health Care System
United States
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