Dr. Keith White – one of the Society of Rural Physicians of Canada’s first Rural Fellows, and a physician with more than 35 years of experience in rural practice – is currently traveling the province on behalf of the Shared Care Committee meeting with the province’s physicians to discuss polypharmacy risk reduction in the elderly.
White is engaging BC physicians as part of his role as Physician Lead for the Polypharmacy Risk Reduction in the Elderly (PPhRR) Initiative, a project that educates and supports doctors in safely reducing the number of medications being taken by the elderly and frail elderly. The initiative aims to improve quality of life and health outcomes, as well as improve provider and elderly patient care experiences.
The PPhRR Initiative’s definition of polypharmacy is the state where the theoretical benefits of multiple medications are outweighed by the negative effect of the sheer number of medications, regardless of class of medication or ‘appropriateness’ thereof. “The problem we have as physicians,” opines White, “is that we look at each individual drug, and not the [cumulative] number [of drugs being taken by a patient.]” Treating from this framework can lead to unanticipated outcomes for patients. “The most consistent predictors of adverse drug events is the number of medications being taken by the patient,” says White. “Twenty per cent of all ER visits are due to adverse drug reactions.”
When a physician reduces the number of “low value” medications a patient is taking, there are substantial benefits for the patient: long-term care homes have communicated stories about patients waking up, becoming more active, getting out of bed, interacting more with families – their quality of life significantly improves. Practitioners benefit as well: nurses spend less time “tied to the drug cart,” pharmacy dispensaries do not need to fill prescriptions as frequently, and physicians are called out less frequently at night to manage a crisis.
The Shared Care Committee formed the PPhRR Initiative in response to concerns received about elder care. The initiative has successfully rolled out its first phase (engagement of residential care) and is now looking to engage acute care/transitional care physicians, as well as community care practitioners. The PPhRR Initiative has engaged with 22 Divisions of Family Practice throughout the province to coordinate and offer polypharmacy reduction to residential care physicians in both urban and rural settings, and is now interested in traveling to smaller communities to engage rural practice teams. “In a rural community, the docs do everything,” observes White, “so by addressing polypharmacy in their office, by addressing it in residential care, there will be fewer adverse drug events resulting in fewer transfers to acute care.” The PPhRR initiative is currently reengaging the Divisions of Family Practice in the context of the GPSC’s residential care initiative, which addresses best practices in residential care.
The PPhRR initiative provides four educational offerings for rural health care teams. (Click here for a list of accredited CME opportunities.) Initially, the team initially engages with a “prime-mover” physician to gauge a community’s interest in polypharmacy reduction. If the community requests the training, the PPhRR team will coordinate and fund an in-community Clinical Learning Session that provides physicians with case-based clinical knowledge, tools, and resources. A parallel “Circle of Care” session is also available to train allied health professionals in polypharmacy reduction.
After the completion of the Clinical Learning Session, interested rural physicians will be approached to take part in PPhRR’s “Train the Mentor” program. The program provides physicians with clinical tools to support meaningful medical reviews to assess a patient’s suitability for polypharmacy reduction and provides support to help mentors populate this information back to their local communities. “We support the mentors through consultation and training to develop a process for sustaining polypharmacy reduction in their community. We hope that there will be an opportunity for these mentors to network. That would be useful, especially in a rural context,” says White. However, the process for sustaining polypharmacy reduction needs to be developed between the community and its Division of Family Practice with support from the Shared Care Committee through the PPhRR team.
The PPhRR Initiative continues to garner much interest. In addition to engaging rural communities, the team was recently contacted by the First Nations Health Authority to discuss possible collaboration. “We’ve asked the FNHA about what they think is best for their communities. And we’re also looking for suggestions about next steps in rural settings.” If your community is interested in discussing polypharmacy risk reduction with the PPhRR team, White encourages you to speak to him or to Margaret English, coordinator for the PPhRR initiative. “We want to support what practitioners want to do.”