Johns Hopkins University School of Medicine
ALIGN: Aligning Medications with What Matters Most (Demo)
Health Care Systems
Johns Hopkins Community Physicians
Dr. Green is an associate professor of medicine in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine. Her research focuses on improving communication between older adults, care partners and health care professionals about unnecessary and potentially harmful interventions, including medication use. As a member of the American Geriatrics Society (AGS) Clinical Practice Committee, Dr. Green co-wrote the Society’s recommendations for Choosing Wisely, a national initiative that promotes patient-physician conversations about unnecessary medical tests and procedures. Dr. Green received the AGS Outstanding Junior Investigator of the Year Award for 2022. Her research, supported by the NIA, is evaluating the impact on patient and care partner outcomes of pragmatic interventions to optimize prescribing for older adults with dementia in primary care. A former award-winning health journalist, Dr. Green has published personal essays and op-eds in Annals of Internal Medicine, The Washington Post, and The New York Times, among other publications.
RATIONALE: In keeping with principles of person-centered care, people should be on medicines that will help them achieve their goals, but not medicines that are likely to be harmful or unhelpful. The use of many medications requires nuanced decision-making to balance potential benefits and harms for people living with dementia (PLWD). Pharmacists and primary care providers (PCPs) working together as interdisciplinary teams can leverage time more effectively and pharmacists can provide evidence-based, individualized deprescribing recommendations.
OBJECTIVE: To conduct a cluster randomized pragmatic trial to test the effectiveness of a pharmacist-led, primary care-based deprescribing intervention for PLWD and their care partners.
SETTING: 20 primary care practices that are part of Johns Hopkins Community Physicians (JHCP), a community-based health care system.
POPULATION: People aged 65 years and older with a diagnosis of dementia and ≥5 chronic medications.
INTERVENTION: ALIGN consists of the following strategies: 1) direct-to-consumer deprescribing educational materials designed to activate the care partner and PLWD; 2) a single telehealth visit in which a pharmacist discusses benefits and harms of the medications with the patient and care partner in the context of their goals and preferences; and 3) pharmacist-PCP communication in which the pharmacist provides tailored deprescribing recommendations that are actionable for the PCP.
OUTCOMES: The primary clinical outcome is the proportion of patients who stop ≥1 medication as a function of the intervention, assessed at 3 months. Secondary clinical outcomes assessed at baseline and 3 months includethe proportion of patients who add ≥1 new medication, the proportion of patients who deprescribe ≥1 potentially inappropriate medication, and the total number of medications. There is one exploratory outcome: CollaboRATE, a patient- and care partner-reported measure of shared decision making. Implementation endpoints include five domains to inform future dissemination: appropriateness, fidelity, feasibility, penetration, and equity.
IMPACT: This ePCT has the potential to show that a pragmatic, pharmacist-led intervention can lead to a significant increase in the proportion of PLWD who discontinue at least one medication by 3 months. Optimizing medications through deprescribing (reducing or stopping medications that are harmful or unlikely to be beneficial) can improve health outcomes and quality of life for PLWD and their care partners.