Jacquelyn Pendergast

Background Deprescribing, intentional medication discontinuation or dose reduction, can reduce potentially inappropriate medication use and medication-related harms. Engaging patients in deprescribing discussions may increase likelihood of deprescribing and promote shared decision-making. Objective To examine the impact of patient-directed educational brochures on patient engagement and deprescribing discussions with primary care providers (PCPs). Design We mailed medication-specific brochures 2 weeks prior to each patient’s PCP appointment (4/12/2021–10/7/2022), followed by a mailed survey 2 weeks after scheduled PCP visits. Participants Patients from three Veterans Affairs facilities with scheduled PCP appointments eligible for one of three medication-based cohorts (proton pump inhibitor, gabapentin, diabetes-hypoglycemia risk). Main Measures Our primary outcome was patient-reported deprescribing discussions with their PCP (yes/no). Descriptive statistics characterized engagement with and reactions to the brochure. Multivariable logistic regression models determined associations of patient characteristics, attitudes, and brochure-engagement with reported deprescribing discussions. Key Results Adjusting only for patient characteristics, discussions were less likely if respondents were Black (vs. White: OR 0.47, 95% CI 0.29–0.78) and more likely with higher education level (e.g., advanced degree vs. high school or less: OR 2.39, 95% CI 1.53–3.73), and adequate health literacy (OR 1.84, 95% CI 1.16–2.92). After further adjusting for general deprescribing attitudes and brochure engagement, discussions were more likely if respondents completed brochure activities (vs. did not read brochures: OR 2.23, 95% CI 1.39–3.59), contacted their PCPs prior to their visits (OR 2.47, 95% CI 1.34, 4.58), or discussed the brochure with family/friends (OR 1.72, 95% CI 1.22–2.41) or a healthcare provider (OR 3.18, 95% CI 2.08–4.85). Conclusions Patient characteristics and brochure engagement were associated with deprescribing discussions. Patient-centered deprescribing brochures can foster patient engagement and inclusion of patient perspectives into deprescribing decisions. Future studies should explore implementation strategies that promote greater deprescribing reach and adoption among patients with lower health literacy.

Background: In the unique context of rural Veterans’ health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. Objectives: We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. Research Design: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. Results: Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. Conclusions: This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners’ efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.