From the 2019 HVPAA National Conference
Dr. Andrew Lewis (Cleveland Clinic Foundation), Dr. Ruchi Sharma (Cleveland Clinic Foundation), Dr. Sajal Akhtar (Cleveland Clinic Foundation), Dr. Andrew Young (Cleveland Clinic Foundation), Dr. Penali Noticewala (Cleveland Clinic Foundation)
Polypharmacy, defined as a patient being prescribed 5 or more medications, is a common problem in healthcare. It leads to decreased compliance, increased risk of medication interactions and side effects, and increased cost to the patient. In the G10 Pod A resident clinic at the Cleveland Clinic Foundation, only 2% of 296 patients seen in clinic had polypharmacy documented, assessed for therapeutic appropriateness, and in the problem list over the 3 months preceding our study.
Our aim was to increase documentation and assessment of polypharmacy by 75% within 3 months.
Using a decision matrix, we identified the lack of utilization of clinical pharmacists by residents, the lack of resident awareness of polypharmacy, and overall decreased knowledge of polypharmacy as targeted areas of focus with low-effort high-impact interventions. We implemented a plan, do, study, act design for our project. Our first intervention involved improving resident awareness of polypharmacy, enlisting the help of clinical pharmacists to mitigate difficult cases, and having resident-led educational sessions on polypharmacy in our clinic. Our second intervention involved adding hard-stops to our epic smart phrases to ensure that polypharmacy is addressed. Our third intervention was standardizing the smart phrases in all residents’ clinic note templates. We used manual chart review to analyze 137 patient encounters to determine whether polypharmacy was addressed in the progress note of each visit. If documented as being present, we searched for documentation that the medications were reviewed to ensure their necessity. If medications were not deemed therapeutically necessary we searched for documentation of their removal. All of these conditions had to be met for the encounter to be given credit for polypharmacy having been addressed.
Our three interventions led to polypharmacy being addressed in 33%, 53%, and 84% of patients identified as having polypharmacy during each respective intervention cycle. This project also led to 86 inappropriate medications being discontinued.
Our project shows that by implementing a standardized approach for all medical practitioners in an outpatient clinic, that polypharmacy can be appropriately addressed and inappropriate medications can be safely discontinued.
This project led to the discontinuation of numerous unnecessary medications resulting in decreased cost to our patients, reduced risk of medication-related adverse events, and increasing the likelihood of medication compliance.