Laurie Kaiser:  Even as an undergrad majoring in chemistry, David Jacobs was thinking about how he could use his knowledge to help people—in particular, patients.

David Jacobs: Yes, I was interested in how patients interacted with medications and what a pharmacist could really do for their patients and in the community.

Laurie Kaiser:  You could say Dr. Jacobs has spent his life since then seeking answers to these questions, obtaining a PharmD degree and then a PhD in epidemiology. And now, as an assistant professor in the Department of Pharmacy Practice at UB, conducting research focusing on expanding the role of pharmacists in the delivery of health care and on improving patient outcomes. Among Dr. Jacobs' many interests is medication-related harm, a mostly invisible yet shockingly major problem in the U.S., affecting millions of older adults and leading to tens of thousands of premature deaths. Dr. Jacobs is currently co-leading a multidisciplinary initiative at UB called Team Alice, designed to reverse this troubling trend through research, education and advocacy.

Welcome to Driven to Discover, a University at Buffalo podcast that explores what inspires today's innovators. My name is Laurie Kaiser, and on this episode I'll be talking to David Jacobs about medication overload and what Team Alice is doing to prevent it.

Welcome, David Jacobs. We're glad to have you here with us today. When you were a kid, you said you were good at science but didn't really have a clear idea of what you wanted to be when you grew up. What led you to pharmacy research?

David Jacobs: Yes, well first, thank you for having me here today. I went, you know, into an undergrad, as you mentioned, in chemistry. I went to my pharmacy school, but after that, I went into clinical training. And a lot of times, when you're working with patients, whether that be in the hospital or out in the community, there's always a lot of questions that we don't have solid answers for. We don't have the evidence, the guidelines, the randomized trials to sometimes support the decisions that we want to do or even the services that we want to provide. So I think it was that sort of background and impact when I was doing my clinical training that kinda put me on a path to doing more research related in pharmacy and in health care.

Laurie Kaiser:  David, you have a very distinctive accent. Can you tell us where you're from and where you grew up?

David Jacobs: Sure, yeah, no, I get that a lot. I did grow up on Long Island. After that, I went, did my undergrad in Binghamton, and I've been in Buffalo for about 10 to 15 years maybe. But as you can tell, I'm still a Long Islander.

Laurie Kaiser: You mentioned that during your clinical training you found things that couldn't be answered by the literature or by randomized trials. Could you talk a little bit more about that? What kind of issues were you encountering and how did that discovery impact your understanding of health care?

David Jacobs: Sure, yes, thank you. So clinical trials or randomized controlled trials are still the gold standard to show the efficacy of treatment, which basically shows whether a medication is having the intended effect. Where it's a little bit limited is when we leave clinical trials and look more at effectiveness or real-world care. What we see in our clinical care are usually high needs, complex patients. So who are those types of patients? Those could be individuals with multiple comorbidities, those that are on 10+ medications, what we call hyper-polypharmacy. And even the interaction that we're now seeing with patients that have social-related needs—transportation, food insecurity. And how does this interact? So what we're finding a lot in our research is that we have to account for both the clinical needs as well as the social-related needs. And this is not really what's being done in our clinical trials or as much in the health care system.

Laurie Kaiser:  Can you briefly describe what the issue is with medication-related harm in particular? What is it and how serious is it?

David Jacobs: Yes, it's very serious. It's estimated there are around 1.5 million medication errors per year, which is causing the health care system about 3.5 billion annually. So my interest has been the research at the transition of care, which is the movement of patients from one health care setting to another. Specifically, if we're looking from a patient entering a hospital and then being discharged back to their home, what we're seeing is that upwards of 30 to 40% of people could have a medication-related problem at that moment. And those medication-related problems could be medication errors, adverse drug events, drug interactions, non-adherence to prescribed regimens, as well as misunderstandings about medication instructions.

Not only that, what we see at that transition of care is communication. That probably in our research comes up as the top one or two issues that occur when a patient's discharged. A lot of that communication's because the health care system is fragmented. It's siloed. Our electronic health records don't always get transferred from one setting to another. So specifically, if someone is admitted at Erie County Medical Center and then goes to another medical center in the area, their health records may not be at that other health care center. This fragmentation of the health system causes communication issues, which then leads to medication-related problems, which could then lead to a patient being readmitted or having other issues that are outstanding after they're discharged.

Laurie Kaiser:  Can you talk a little bit about medication overload?

David Jacobs: Sure, medication overload. So we've done some preliminary work utilizing a national database and the question we asked is: What are the trends over time in those that, in patients or subjects, that are polypharmacy, so being on five or more medications, or hyper-polypharmacy, being on 10 or more medications. And especially among older adults, that's what we've focused on. And what we've seen over about the past 20 years is that trend is increasing. More and more individuals, especially at the hyper-polypharmacy, that 10+ medications, are on multiple prescribed medications, over-the-counters and herbals.

And then the question we kind of asked is, can you de-prescribe some of the medications that an individual is on? So this is a multidimensional question because you need the provider on board, but you also need the patient on board. Sometimes they've been on a medication for a very long time and when you ask them why they're on the medication, they may respond, "Just because. You know, I've been taking it forever." But it may not be necessary anymore, it may not be appropriate anymore. So it's really a conversation of, can we review that med list? And a lot of times when we review med lists or we're in a clinical setting, it's all about prescribing medications. And now, we're kinda looking at it the opposite. And I would say, you know, there is a large movement across the country in the area of de-prescribing. And it's not just the U.S. You know, you're seeing an international movement as well.

Laurie Kaiser:  Let's talk about Team Alice. Starting with the name: Who was Alice?

David Jacobs: Alice at the time was an 88-year-old who, just prior to a series of unfortunate events, was a vibrant, vibrant lady. She was on the steering committee for her 70th high school reunion. She was living on her own. She drove her own car and did her own finances. At the time, she had a little bit of neck pain. Her primary care provider was unavailable, so she went to the emergency department at a hospital. That provider prescribed a medication known as Flexeril. Now, Flexeril, or cyclobenzaprine is the generic name for it, is a potentially inappropriate medication for older adults. Why is that is because it could cause confusion, delirium, as well as impairment.

At that time, she was lucky enough where her daughter noticed that she was on that medication and made sure that she did not take it. Well, about a week later, she had a little bit of knee pain, went to a specialist, and the specialist sent her back to the hospital. That same hospital, actually, where she was prescribed the Flexeril initially. Forty-eight days after that hospitalization, a series of health care-associated infections led to her untimely death. The root cause of that death was actually the prescribing of Flexeril, where she was re-prescribed that medication when she went to the hospital a second time.

Because of that, Team Alice was formed. It's co-led by Dr. Ranjit Singh out of the Department of Family Medicine and Dr. Bob Wahler at the Department of Pharmacy Practice, both here at the University at Buffalo.

Laurie Kaiser:  How has the team evolved over the years in terms of the team itself and the work it's doing?

David Jacobs: Sure. I would say this is probably one of the more interdisciplinary teams that I've been a part of. Not only do you have medicine as well as pharmacy, but within the university we have collaborators from communication, social work, nursing, computer science, engineering, among others. And we're all kind of working together to look at this problem in different ways. Not only do we have an interdisciplinary academic team, but we also have a community of collaborators. Patients. So we do a lot of community-based research. Over time, the work has really expanded to kind of deal with this problem holistically, because it really does take a team approach in order to deal with most health care problems, and this one specifically.

Laurie Kaiser:  Now, Team Alice recently received almost $2 million in national funding for research in which you're a principal investigator. How do you plan to use this funding?

David Jacobs: So this was a great grant from the Agency for Healthcare Research and Quality. I am a principal investigator along with my colleagues Ranjit Singh and Dr. Winnie Chen from engineering. It's an interdisciplinary grant. The goal of this grant is really to kind of focus on medication safety at the transition of care among older adults in underserved areas. We teamed up with Erie County Medical Center.

What I really like about it is that it's a learning lab. So a lot of grants that you go into, you have to have an intervention and you kind of evaluate that intervention. What AHRQ wanted to do here was for us to identify a problem and then to kind of work through that problem. And the first part of that is called the problem analysis phase. So we're going to be doing things such as interviews and surveys with patients in the community that were recently discharged. We're going to be doing cognitive work analysis, systems engineering for what's going on in the hospital. And then we also actually teamed up with HEALTHeLINK [an electronic health record database in Western New York], who will be helping us from a system level to kind of look at the electronic health data and maybe how can we better identify those that are either at high risk for readmission or those that need a medication reconciliation before they leave or after they leave the hospital.

In the second phase of that grant, what we're gonna be doing is really developing interventions. What did we learn from this problem analysis phase that we could then develop interventions, simulate them, and then really pilot test. So overall, it's really this opportunity to target and evaluate that transition of care that we were talking about earlier and medication safety.

And again, being at ECMC, also being in the area of Buffalo, we could kind of see that interaction of how some of the social-related needs kind of interact with the person's care after they leave the hospital, how we can improve upon that with different interventions or different types of services that we can provide so that we can improve their transition from the hospital to home.

Laurie Kaiser:  Systemic change can take years or even decades to happen. What can a person do who is currently in this situation or has an older relative in this situation to keep themself or their relatives safe?

David Jacobs: Yeah, so we did some additional research a few years ago working with patients and caregivers when they actually transitioned from hospital to home. And we had different questions that we asked based on their clinical and their social needs after they were discharged. And what we came up with was sort of a “five points to consider when you are being discharged from the hospital.”

The first one was, If you see something, say something. If you notice a new symptom or your loved one is actually acting unusually different, report it to the health care team immediately.

Second, keep asking questions to the health care team. Sometimes, patients and even loved ones, they feel uncomfortable asking questions, right? It's a very challenging time in the hospital. Health care professionals, staff, are coming in and out. Patients wanna obviously leave. But they need to keep asking questions to their team until they get the answers they need.

Third, document everything. Be sure to document what you're told by your providers, including new diagnoses, medication changes, status of health conditions, so you may advocate for your loved one when needed.

Fourth, know before you go. Be sure that you and your loved one understand all discharge instructions and all their needs are met before you leave the hospital.

And then the fifth takeaway point that we found was, be prepared. Have all your legal paperwork regarding your loved one's medical wishes, your list of medications and list of providers up to date and ready to provide at any time during their transition from hospital to home.

Laurie Kaiser:  That's excellent advice. It seems like it's a lot just staying organized and keeping your records up to date.

David Jacobs: Yeah, you know, just having an updated medication list is probably one of the most important things. We even tell some people, just bring your bag of medicines, bring it into the hospital, this is what I'm on, and they'll work through it. So we talk a lot about the discharge from hospital to home, but it's even a challenging time when they're coming in. Again, we live in a fragmented health care system. So just because you got a new medication from a specialist, that doesn't mean that that information is at the hospital. So it's important to kinda have either an updated list of your conditions and your medications, but even just as easy is grab a brown bag, put all your bottles in it and bring it to the hospital.

Laurie Kaiser:  Are there any particular medications or classes of drugs that people should be wary of as they get older?

David Jacobs: So the American Geriatric Society puts out a list of Beers meds, which are potentially inappropriate meds for older adults. This is a large list. It contains over three dozen individual medications that should be avoided and then about 40+ medication classes that should be used in caution.

I would probably go back to what I mentioned before: Have that list of medications ready. Ask questions. If a new side effect is occurring or unusually different, ask whether it could be medication-related first. That should be the first question. Leverage your health care provider. Make sure that they are asking the questions. And then if you want to go and say, "Am I on any Beers medications and why?" I think that's a great question. They will know what you're talking about, what that list is. It's widely disseminated. It's been around for a long time.

And especially as you age, and we're looking at older adults, we've done some work where we looked at, Are they on these medications? And they commonly are. So it is something that you want to advocate and talk about, whether you should be on it. Sometimes it is appropriate. But you know, sometimes we should, you know, could try to avoid some potentially inappropriate meds. So asking those questions and being proactive in your care—it’s challenging but it's important.

Laurie Kaiser:  Yeah, absolutely. Well, as America is aging, you know, we're going to be an older country, this is the most timely type of research to be doing, really.

David Jacobs: Yeah, I agree with you wholeheartedly. It's definitely something that myself, our team, we care about. Team Alice, the founders, the leaders now, we've been doing this for many years, multidimensional as you can see. And you know, we're excited about this new opportunity and we're always looking for what is that next step. And the question that we typically go back to is, what we're doing, would that save Alice?

So, you know, thank you for the opportunity to talk about myself a little bit as well as this research. I think there are really some exciting opportunities, both with what we're currently doing now and in the future.

Laurie Kaiser:  Thank you, thank you so much.

David Jacobs: Thank you.