Taking Healthcare by Storm: Industry Insights with Dr. Tamara Ruggles

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Tamara Ruggles, PharmD, BCGP, FASCP, a Board-Certified Geriatric Pharmacist, Fellow of the American Society of Consultant Pharmacists (ASCP), founder of The Deprescribing Clinic, and host of the Geriatric Pharmacy Focus podcast on the Pharmacy Podcast Network.

Dr. Tamara Ruggles explains how medication-related harm and prescribing cascades in long-term care led her to found the Deprescribing Clinic to help patients optimize medications, reduce anticholinergic burden and side effects, and improve quality of life. She also highlights pharmacists’ roles in antimicrobial stewardship and pharmacogenomic testing to reduce adverse events, while advocating for broader coverage and reimbursement for pharmacist clinical services.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-042426-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

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Hi everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director here at Quality Insights. Today's guest is Dr. Tamara Ruggles, a board certified geriatric pharmacist. Fellow of the American Society of Consultant Pharmacists who has dedicated her career to improving medication safety and quality of life for older adults. After years of working in a long-term care pharmacy, she saw firsthand how inappropriate medication use could lead to false. Hospitalizations and even nursing home admissions. That experience led her to launch her own consulting company, which has grown from serving just a few rural facilities to supporting more than 20 long-term care communities across North Dakota. She is, as I say, a hero about, I say shero, and she is certainly a shero. She's also the founder of the de-Prescribing Clinic, a community-based practice focused on helping patients and providers optimize medications, reduce side effects, and use tools like pharmacogenomics and antimicrobial stewardship to deliver safer, more personalized care. In addition to her clinical work, she hosts the Geriatric Pharmacy Focus podcast. Check it out. Awesome. So much high yield information and she remains closely connected to patient care through community pharmacy practice. Today we're gonna be exploring the power of de-prescribing the risks of polypharmacy in older adults. The role pharmacists can play in improving outcomes in long-term care and the what the future of medication management can look like if we truly, truly prioritize safety function and quality of life. Tamara, Tamara Ruggles. Thank you so very much for joining me today. Wow. Thanks so much for that kind introduction. I appreciate that. My kids, you know, they wouldn't introduce me in such a nice light as you have, so thank you. Well, well deserved. Well deserved. So you spent years working in a long-term care pharmacy before launching your own consulting company and eventually the Deprescribing Clinic. What were you seeing at the bedside that you felt like you needed to make this change, that something needed to change? Yeah. So as far as launching the de-prescribing clinic, when I was, I've been a nursing home consultant pharmacist for over 10 years now, and as, as I'm consulting and as I am seeing these beautiful people come in our nursing homes, you look at their medication list and you think, well, it's no wonder you fell and fractured your hip. You're on a benzo and an opioid and an anticholinergic, and you just look at all their different. Medications they're on. And I started thinking for a couple years, I was thinking, man, if I could have helped this patient a year ago, two years ago, they might not be in this nursing home right now. And not that our nursing facilities aren't great because they are, but most people prefer to be in their own home. And of course, we prefer that these patients don't fall and have fractures. And have a decreased quality of life. So I really just wanted to get to these folks before they ended up in a position where they were having side effects and medication related problems to prevent these kind of things from happening. And after a year of seeing it over and over again, I thought, that's it. I'm doing it. I'm starting it. And so that's, what led me to launch the Deprescribing Clinic in 2023. It is so, such a important, uh. Priority. I mean, I don't know if people realize, I mean, de-prescribing like that needs it. Like it's the heart, it's at the heart of geriatrics and it, it needs to be there. Like we kind of just always wanna, I think in our society just add on, add on, add on other medications. But you know, the power of taking things in the way is huge. Yeah. Yeah, most definitely. Well, I think a lot of people hear the de-prescribing in clinic and think, you know, wow, you know, people go from being on 23 medications to three medications, and sometimes there is drastic changes like that in patients when you really, you know, get to the heart of it and dig and see what was first and what was second and the prescribing cascade. But. Big things can happen. Big improvements in health can happen just by simple medication changes too. So yes, there are those huge, drastic changes, but there are, also simple changes that make drastic improvements in people's lives. Definitely. And I've seen that myself. So that leads me to my next question. So what does the clinic actually do? And, yeah. Yeah. Why is it so critical? Why is Deprescribing so critical for older adults and nursing home residents? Yeah, so when I launched the Deprescribing clinic, I had in mind that it was gonna be a lot of older adults on way too many medications and making these huge changes. And it has been some of that. But I have been surprised, that the clinic see, I mean, I see patients. Of all ages at the de-prescribing clinic. Um, my clinic is located inside a community pharmacy, so it's very nice that I have an office inside the community pharmacy I work at, to have that continuity there. But I do see people of all ages and I offer pharmacogenomic testing. I offer, cognitive decline, risk reduction is what I call it. But basically looking at anticholinergic and medications that affect cognition. Then also I look at drug induced nutrient depletion. So those are the big areas I focus on. I do big de-prescribing services for people that are on, you know, 30 medications, trying to get it down to something that's manageable for the patient and to decrease risk, but still appropriately treat all their comorbidities. So I will say that. After launching the Deprescribing Clinic, the biggest, seller, I guess you could say, or the service that people want the most is the pharmacogenomic testing. And that is people of all ages. It is kids with a DHD, young adults and adolescents with anxiety and depression. And then of course your older adults who are on so many different medications and we're trying to figure out what's working, what's not, and what's probably causing too many side effects. So, that is. For sure the biggest, um, the biggest service I offer, um, which has been a surprise to me, has been that pharmacogenomic testing. Yeah, I'm excited to get into that. I'm, I'm, we're going to most definitely, I, I wanted to, focus on, lay the groundwork here. So from your work across 20 long-term care facilities, what are the most common medication related problems you see? I've seen your posts on LinkedIn and you focus a lot on anticholinergic burden. And you know, is so very important and I think it's often overlooked. So what, what do you see most commonly? There are medication related problems with anticholinergic burden, side effects, or drug induced nutrient depletion, which is huge. Yeah, for the most common problem is definitely the prescribing cascade. So you see a patient, you know, started a lot of times, you know, this starts with an anticholinergic, right? So they're started on Oxybutynin and pretty soon they have dry mouth. So they're, and they're on a, a biotene mouth spray, and they develop constipation. So they're on some Senna. Then they develop tachycardia from being on an anticholinergic. So now they're on propanolol, uh, a beta blocker. And from being on the propanolol, they get some broncho constriction. So now they're on an albuterol inhaler and maybe Advair. And so you can just see how this continues, this prescribing cascade. And if you don't get to the very first medication that was prescribed, it's hard to see. The rest of the prescribing cascade occur, but I think anytime there's a new problem in a nursing home patient, let's first assume it's a side effect. Let's just first look at the meds and see could this be a side effect instead of a new disease state or a new concern that the. The patient is facing. So I will say that I think the prescribing cascade is one of the biggest medication problems that I see, and it often starts with an anticholinergic. And you know, those anticholinergics, luckily with the beers criteria and the stop start criteria and different, um, organizations, you know, really making the awareness that anticholinergics do pose a lot of risk. Now. Now we're looking at it more. We're seeing it more, we're spotting it, and there's other alternatives for most of these medications. I look at Peroxetine. I mean, it's a highly anticholinergic medication, and we have many other SSRIs that we could use as an alternative. So luckily there's lots of alternatives we can use. And also, you know, thankful to the American Geriatric Society and others, there's more awareness to the anticholinergic burden issue facing all of us, but especially our older adults. Yeah. Yes. All yes. All of those things you mentioned is so very important. And, and another, another big problem in nursing homes that I've seen and, and, uh, you know, I'm sure you've seen. Antibi Antibiotic use. So you are certified in antimicrobial stewardship and actively involved in this. Um, how big of an issue is antibiotic misuse in nursing homes today? And I'm just gonna throw this in. I was talking with a family member yesterday who said to me, it's just antibiotics. I don't understand why the doctor doesn't just prescribe them when we ask. Yeah, right. Like that is like a, that's huge. Right? That's the issue. So what role should pharmacists play in strengthening stewardship efforts? Right. I'm Antimicrobial. Resistance is a global public health threat, and when you look at the data, it is pretty alarming to see just how big the threat is everywhere, including the United States. So pharmacists have a huge role to play in this, because we have such an involvement in. Both nursing homes and in the community. I will say in my nursing facilities, I take a very active role in antimicrobial stewardship, helping create policies, attending monthly antimicrobial stewardship meetings, looking at different criteria. Some of the things that we've done is we've placed, a cap on the duration of antimicrobials to treat an uncomplicated UTI. We were having an issue in one of my nursing homes where. UTIs were being treated for 14 days when they could probably only need to be treated for five to seven days. So just looking at those kind of policies to see if we can help with resistance in our facilities. Also, why are we starting an antibiotic? Is, is there warrant to starting one? You know, a different colored urine isn't a reason to start someone on antibiotics for a UTI. Your mom acting funny. You know, we don't need to go get A-U-A-U-C right away. We can look at other things as she dehydrated. Um, you know, there's many other things to look at. So using the lobe criteria to determine if. We even need to treat a UTI is a good thing. And a lot of this boils down to education and pharmacists can be great resource to educating, um, nurses and others on when it might be appropriate to look at treating and when it might be appropriate to just monitor. And so another one is even just skin. You know, a resident takes a bath and there's redness on their skin. Well, that's not really a reason to start. Nystatin. Can we start with a barrier cream or an intra die sheet or can we, can we monitor and start. you know, a different intervention instead of going right to that Nystatin. And so, these are always, pharmacists can be involved in antimicrobials, steward, chip because we do need to use these medications judiciously, or we're gonna have a big problem on our hands. And we already kind of do in with some bacteria and some bugs like, candida oris coming and other resistant organisms. Yeah. Yeah. And I, I remember thinking during the pandemic, like the, the nursing homes, you know, might be the place where like something starts that, really ruins, I don't wanna say ruins, but like, takes down the whole world, right? Like all of these super bugs are developing there. Like, it's, it's really, um, you know, a big problem. , So we do need to get a handle on it. I think trying to get facilities to buy in to dupe de-prescribing, it's not flashy. It doesn't like, seem like it's gonna, impact the bottom line for these facilities. So I. People don't realize how much medication use can influence quality measures in nursing homes because it's, you know, kind of under the surface. So how do medication related side effects and polypharmacy quietly impact outcomes that facilities are being measured on? Yeah, when you look at the data that nursing facilities receive and what's flagging on their Casper report or, or different, you know, measures, look at anti-psychotic use and that's a big one. Uh, so trying to get your anti-psychotic use down. Finding ways to manage behaviors other than going to anti-psychotics now. Sometimes you just simply can't, depending on diagnosis and other factors. But getting those rates down can help with quality measures. Preventing falls and falls with major injury. That is huge for helping out quality measures. Preventing rehospitalizations and getting your rehospitalization rates down certainly helps with quality measures. So there's a lot of areas where, reducing polypharmacy and starting a de-prescribing process can really help. Nursing homes in so many ways, but yes, improvement in quality measures. Look at even OTC medication and OTC medication use. That's something that these nursing facilities pay for. Getting that down can help the bottom line look at the time to administer medications, safety of patients. The less medications there are to administer, the safer that those, patients can be in reducing time and reducing burden. So there's many, many ways. That just having patients be on appropriate medications can improve quality, can improve the bottom line, can improve nursing time, and then improve, patient safety, which is the biggest goal. Yes. And, and I wanna kind of finish up our, our nursing home discussion, though I could talk for a long time because I, you know, nursing homes are in my heart. But based on your experience, what is the single greatest medication related risk facing nursing home residents right now? And and what does it keep you up at night and what keeps you up at night about it? Well, lots of things keep me up at night, but. Uh, the risk of course, I think right now and kind of post pandemic is we have a shortage of people working in our nursing facilities and that the shortage of staff leads to the decreased amount of time to do your job. And, we don't wanna rush through a job, but we certainly don't wanna rush through dispensing medications to patients. And when you look at all the different medications patients take, giving someone the wrong medications terrifies me. I mean, I've seen it happen. I've seen someone get an Oxycontin that was never on Oxycontin and end up on a Narcan drip in the ICU. So you see these things happen and you just never want a patient to be harmed. And so my biggest fear is with. Shortage of, people working in nursing facilities, that mistakes happen, things get rushed. Do you check a blood pressure to make sure the, the parameters are being met to give that digoxin or to give that beta blocker? Are you checking a person's blood sugar? Is to ensure that you're giving 'em the right amount of insulin? I mean, I've seen it rushed where they. Someone just used the blood sugars from the night before to give the insulin today. Well, that's terrifying. So the shortage and the rushed, you know, dispensing of medications to patients and administering medications is my greatest concern as far as nursing homes and patient safety goes. Mm, yes, I would. Yes, agree. And I didn't see that coming as the, as your, as the, the risk. But I would agree with you. So, I, I wanna get to the pharmacogenomic testing. You've incorporated this testing into your, uh, deep prescribing work. How do you see pharmacogenomics changing the way we manage medications in older adults and long-term care settings as well? Oh, I hope this begins to be used from the time, you know, children start being prescribed medications to all the way through the entire lifespan to prevent side effects and to get the most outta medications. So, I mean, there's so many different studies, but there was one done with thousands of patients across multiple health systems where they simply did pharmacogenomic testing in one arm and no. And just, you know, normal healthcare without pharmacogenomic testing in the other arm. And just by doing the pharmacogenomic testing and using it to guide prescribing adverse events were decreased by 30%. Well, that's a big deal because adverse events are the what, the third leading cause of death in the United States. Now if you look@thatthirdcause.org. So reducing by 30% just by using the test and using it to guide prescribing habits is huge. And we know our older adults are more prone to side effects. Their kidney function has decreased possibly, liver impairment. They're more frail, more body fat, just different body composition, less muscle mass. They're so much more prone to having side effects. So by using pharmacogenomic testing, if we can decrease that, that's huge in our older adults. And huge honestly, in anybody who is ever gonna take a medication. It's a simple cheek swab. It's covered by Medicare. Why are we not utilizing this amazing tool that we have to prevent side effects and help patients get the most out of their medications? Even looking at clopidogrel, if you have a heart attack, I mean, you certainly wanna ensure you don't wanna have another one. And how do you know that that clopidogrel is working if you don't do a pharmacogenomics test? So I get so many people and so many providers say to me, I don't need a pharmacogenomics test, because if someone's having a side effect, I'm gonna switch their medications. I get that valid argument, but not for every medication, because when you look at clopidogrel, how are you gonna know it's not working until they have a repeat heart attack or some type of adverse event from that medication not working. So let's just use it. Let's use that swab. Let's know if that medication is working for you or not, and let's prevent side effects. Yeah, very basic, straightforward, common sense. Yes. Yeah, absolutely. Yes. So looking ahead, where do you see the de-prescribing clinic in five years? And maybe this is a two part question. So where you see the de-prescribing clinic in five years, and if you were shaping healthcare Policy nationwide, what role would you want pharmacists to play in caring for older adults that we're not fully utilizing today? Yeah, great questions. Uh, when it comes to the Deprescribing Clinic, I'm so thankful that it's, you know, been around almost three years now. I started it, I really didn't know. How it was gonna go if people were gonna come. And honestly, I've never advertised. So the fact that it's still going just by word of mouth, I'm so grateful that these people trust me and come to me and wanna get tested. And I love it. I absolutely love it. So I hope in five years it's just, it's still, it's still going and it's reaching more people. I hope different de-prescribing clinics pop up across the United States to help people. Right now I'm working, on a grant, which I'm so thankful for. I'm, I'm doing a grant in collaboration with North Dakota State University. And we're doing pharmacogenomic testing in nursing home patients and tracking data. As far as how many, you know, major gene drug interactions are there, how many moderate interactions, how many, what percentage of our nursing facility patients are a CYP 2D six intermediate metabolizer? What percentage are a poor metabolizer, um, number of meds before and after pain scores, depression scores before and after. So I hope to keep. Doing studies like this to prove benefit of pharmacogenomic testing. So that, hopefully to answer your second question, pharmacogenomic testing is more widely covered by insurance companies because right now I can get Medicare to cover. A swab under Part B with a qualifying medication and diagnosis, for once in a patient's lifetime, which is amazing. But I'm having difficulty getting coverage from Medicaid and from commercial insurances and also for Medicare Advantage plans. So I would love to see, uh, more coverage for pharmacogenomic testing because it does make such an impact and reduce side effects, reduce hospitalizations. Reduce polypharmacy, so it's definitely worth the money. Studies have proven that, and also in the future, I love that pharmacists get reimbursed for dispensing prescriptions and get paid to dispense prescriptions. I think our community pharmacists have such an important role and I love our community pharmacists. I would also like to see pharmacists get reimbursed for. For monetary value, not tied to prescriptions. So preventing hospitalizations, preventing rehospitalizations, preventing polypharmacy, decreasing anticholinergic burden. Those clinical services that we offer, I would love to see us get reimbursement for. And I know there are things like outcomes, MTM, which I do, and I'm grateful for them too, but getting paid $10 to get somebody on a statin who has diabetes. Is great, but it doesn't, it doesn't do justice for what pharmacists can offer the United States when it comes to healthcare and improving healthcare. So I hope pharmacogenomics is more widely covered and pharmacists are paid for the services that they're able to offer. I love that. That's gotta be the, the buzz line for the podcast. If, if people wanna find out more about you and your work, how can they do that? Yeah, I'm on LinkedIn so you can catch me there or just the de-prescribing clinic.com. Uh, you can find me there and yes, please reach out. I love working with different people and getting kind of the word out about all pharmacists can do and the power of pharmacogenomics. And your podcast. Let's plug your podcast. Oh yeah. And my podcast, the Geriatric pharmacy focus on the pharmacy podcast network. Yes, I love podcasting. Yes. Highly recommend Dr. Tamara Ruggles I love this conversation. Thank you so much for joining me today. Yes, thank you for having me.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.