Amy Linsky, MD, MSc
Tell us about your background and why you were interested in studying polypharmacy.
I completed my training in Internal Medicine, but I knew that I had interest in improving population health in addition to providing direct clinical care. I completed a General Internal Medicine fellowship where I learned about health services research and methods to study many of the complex issues around health care. During my fellowship, I recall seeing an older man who was on warfarin, but he did not know why he was taking it. Despite some sleuthing, I never found an indication for why it was started, yet I was hesitant about stopping it. At that point, I realized there was often little guidance about making decisions to discontinue prescriptions.
What are some of the main issues surrounding the care of older adults that you are currently working on with the VA?
My research portfolio primarily focuses on “deprescribing,” which has been defined as the proactive, intentional discontinuation of medications that may no longer provide benefit or whose potential risks outweigh potential benefits. It is considered part of the good prescribing continuum and should occur within the context of patients’ goals of care. Many older adults, both within the VA and in the community, take multiple medications, so addressing the complexities of polypharmacy and fostering deprescribing where appropriate is one issue I am currently working on.
Care coordination is a big issue for all patients, particularly older adults. How does pharmacy fit into care coordination?
As mentioned, many older adults take multiple medications, including prescriptions and those available over-the-counter. These medications can also be obtained from different prescribing clinicians or from different pharmacies, and as a result, it creates a risk for undetected drug-drug interactions or unintentional therapeutic duplications. Even within a unified healthcare system such as the VA, we have found that complexity in filling locations can lead to discrepancies between what the patient is taking at home and what is documented within the electronic health record. These problems are likely magnified with fragmentation of healthcare delivery. Having the time and capacity to do a thorough review of medications, reconciling any discrepancies between what the patient is taking and what is listed in the medical record, can be difficult in an understaffed practice setting. Pharmacists have had success at filling this need in a variety of settings due to their specialized training and by building relationships with patients.
There seems to be fear from many when it comes to deprescribing or not getting specifics tests or scans done. Why do you think that is? How is that changing?
I think there is a general sense among clinicians that doing something is better than doing nothing. Healthcare providers – and US society in general – often function under a presumption that “more is better.” As such, clinicians face internal and external pressures to order diagnostic tests and treatments. There has been a fair amount of research evaluating how to prevent the inappropriate initiation of care (for example, not starting antibiotics for viral illnesses), but there are additional cognitive barriers to discontinue something once it has already begun. Understanding and addressing these types of problems is part of de-implementation research.
The VA sees a larger percentage of older adult patients than clinics that treat the general population. How does that affect your work?
From a research perspective, it means that there is a population for whom the type of issues I study will yield benefit. However, it is not just patients age 65 and older who experience polypharmacy, and the work I do is applicable to patients of all ages. While there is a common definition of polypharmacy as 5 or more medications, others advocate that having just one inappropriate or unnecessary medication better captures the concept.
Where do you see this focus on polypharmacy going in 10 years? 20 years? What do you hope to see from this focus?
I think that the concept of polypharmacy has been present within the geriatrics and primary care communities for a while, but that broader interest in deprescribing is still in its infancy. There has been a lot of momentum in the past decade, both within the US and internationally, to promote research into how to incorporate deprescribing into routine clinical care in order to provide safe and high quality care to patients. I hope to see this effort yield tangible and measurable outcomes in both clinical measures and patient satisfaction.
Amy Linsky, MD, MSc is a clinician-investigator in the Section of General Internal Medicine and at the Center for Health Outcomes and Implementation Research (CHOIR) at VA Boston Healthcare System. She is an Assistant Professor at Boston University School of Medicine. Dr. Linsky is a practicing internist in VA Primary Care. As a recipient of a Career Development Award from VA Health Services Research and Development, Dr. Linsky’s research interests focus on improving the safety and quality of medication use, with a specific interest in reducing overmedication and polypharmacy via deprescribing.