Methods for evaluating the benefit and harms of deprescribing in observational research using routinely collected data

Billing Deprescribing Interventions: Portrait of an Initiative in Québec, Canada

BACKGROUND

Deprescribing is a patient-centred process in which a healthcare professional reduces or stops medications to improve health outcomes. Since late 2022, community pharmacists in Québec, Canada, have been able to bill for deprescribing interventions, enabling more robust deprescribing research in large cohort studies.

OBJECTIVE

This study aimed to assess the prevalence of deprescribing claims in Québec community pharmacies from January 1, 2023, to November 30, 2024, and to identify the most commonly deprescribed medication classes.

METHODS

We analysed the total number of deprescribing claims submitted by pharmacists during this period and categorized deprescribed medications using the American Hospital Formulary Service classification.

FINDINGS

Over 90 000 claims were submitted for deprescribing interventions, with most involving central nervous system medications. Although the number of claims increased over time, the overall volume remained modest.

CONCLUSION

While limitations remain, such as the gradual adoption of billing interventions, Québec's reimbursement model for deprescribing interventions provides an important framework for research, offering a mechanism to study deprescribing in real-world settings.

Withdrawal of antihypertensive drugs in older people

BACKGROUND

Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, and heart failure, as well as chronic kidney disease, cognitive decline, and premature death. Overall, the use of antihypertensive medications has led to a reduction in cardiovascular disease, morbidity rates, and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions and drug-drug interactions, and can contribute to increasing medication-related burden. As such, discontinuation of antihypertensives may be considered appropriate in some older people.

OBJECTIVES

To evaluate the effects of withdrawal of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults.

SEARCH METHODS

For this update, we searched the Cochrane Hypertension Specialised Register, CENTRAL (2022, Issue 9), Ovid MEDLINE, Ovid Embase, the WHO ICTRP, and ClinicalTrials.gov up to October 2022. We also conducted reference checking and citation searches, and contacted study authors to identify any additional studies when appropriate. There were no language restrictions on the searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years of age and over). Eligible participants were living in the community, residential aged care facilities, or based in hospital settings. We included trials evaluating the complete withdrawal of all antihypertensive medication, as well as those focusing on a dose reduction of antihypertensive medication.

DATA COLLECTION AND ANALYSIS

We compared the intervention of discontinuing or reducing the dose of antihypertensive medication to continuing antihypertensive medication using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables, and Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes were mortality, myocardial infarction, and the development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included hospitalisation, stroke, blood pressure (systolic and diastolic), falls, quality of life, and success in withdrawing from antihypertensives. Two review authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment.

MAIN RESULTS

We identified no new studies in this update. Six RCTs from the original review met the inclusion criteria and were included in the review (1073 participants). Study duration and follow-up ranged from 4 weeks to 56 weeks. Meta-analysis of studies showed that discontinuing antihypertensives, compared to continuing, may result in little to no difference in all-cause mortality (OR 2.08, 95% CI 0.79 to 5.46; P = 0.14, I2 = 0%; 4 studies, 630 participants; low certainty of evidence), and that the evidence is very uncertain about the effect on myocardial infarction (OR 1.86, 95% CI 0.19 to 17.98; P = 0.59, I2 = 0%; 2 studies, 447 participants; very low certainty of evidence). Meta-analysis was not possible for the development of adverse drug reactions and withdrawal reactions; the evidence is very uncertain about the effect of antihypertensive discontinuation on the risk of adverse drug reactions (very low certainty of evidence), and the included studies did not assess adverse drug withdrawal reactions specifically. One study reported on hospitalisations; discontinuing antihypertensives may result in little to no difference in hospitalisation (OR 0.83, 95% CI 0.33 to 2.10; P = 0.70; 1 study, 385 participants; low certainty of evidence). Meta-analysis showed that discontinuing antihypertensives may result in little to no difference in stroke (OR 1.44, 95% CI 0.25 to 8.35; P = 0.68, I2 = 6%; 3 studies, 524 participants; low certainty of evidence). Blood pressure may be higher in the discontinuation group than the continuation group (systolic blood pressure: MD 9.75 mmHg, 95% CI 7.33 to 12.18; P < 0.001, I2 = 67%; 5 studies, 767 participants; low certainty of evidence; and diastolic blood pressure: MD 3.5 mmHg, 95% CI 1.82 to 5.18; P < 0.001, I2 = 47%; 5 studies, 768 participants; low certainty of evidence). No studies reported falls. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias).

AUTHORS' CONCLUSIONS

The main conclusions from the 2020 review still apply. Discontinuing antihypertensives may result in little to no difference in mortality, hospitalisation, and stroke. The evidence is very uncertain about the effect of discontinuing antihypertensives on myocardial infarction and adverse drug reactions and adverse drug withdrawal reactions. Discontinuing antihypertensives may result in an increase in blood pressure. There was no information about the effect on falls. The evidence was of low to very low certainty, mainly due to small studies and low event rates. These limitations mean that we cannot draw any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for the use of antihypertensive medications, such as those with frailty, older age groups, and those taking polypharmacy, and measure clinically important outcomes such as adverse drug events, falls, and quality of life.

Evaluation of deprescribing services in frail patients: a systematic review

BACKGROUND

Deprescribing, a process of dose reduction or withdrawal of inappropriate medication that no longer has benefit, is a proposed intervention in the care of older adults living with frailty.

OBJECTIVE/AIM

To evaluate the safety, effectiveness, and clinical impact of deprescribing services in frail patients.

METHODS

A systematic literature search was performed in November 2023 using Scopus, CINAHL PLUS (EBSCO), MEDLINE (OVID and EMBASE), and Cochrane Library. The Mixed Methods Appraisal tool was used for appraising the methodological quality of the included papers. Studies were selected after title, abstract, and full-text screening, with independent review. Thematic analysis was used for analysing data from the selected articles.

RESULTS

Five hundred ninety unique titles were identified, with nine (six trials, one interview, one survey, and one designed-delay study) meeting inclusion and exclusion criteria. Four main descriptive themes have been identified: challenges of deprescribing in frailty, facilitators of deprescribing in frailty, deprescribing processes in current practice in frail patients, and deprescribing outcomes. Additionally, two analytical themes have been identified: safety and quality.

CONCLUSION

A number of issues have been highlighted that impact the implementation of deprescribing services in frail patients. Currently, there is limited evidence showing strong benefits of such deprescribing services, such as reducing the number of potentially inappropriate medications and medication costs.

Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data

BACKGROUND

Limited research has evaluated the validity of claims-based definitions for deprescribing.

OBJECTIVES

Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization.

METHODS

We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity.

RESULTS

Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity.

CONCLUSIONS

The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.

Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper

Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.

Impact of deintensifying hypoglycaemic drugs in older adults with type 2 diabetes: protocol for an emulation of a target trial

INTRODUCTION

In older adults with type 2 diabetes (T2D), overtreatment with hypoglycaemic drugs (HDs: sulfonylureas, glinides and/or insulins) is frequent and associated with increased 1-year mortality. Deintensification of HD is thus a key issue, for which evidence is though limited. The primary objective of this study will be to estimate the effect of deintensifying HD on clinical outcomes (hospital admission or death) within 3 months in older adults (≥75 years) with T2D.

METHODS

We will emulate with real-world data a target trial, within The Health Improvement Network cohort, a large-scale database of data collected from electronic medical records of 2000 general practitioners in France. From 1 January 2010 to 28 February 2019, we will include eligible patients ≥75 years who will have T2D, a stable dose of HDs, glycated haemoglobin A1c (HbA1c) value <75 mmol/mol (9.0%) and no deintensification in the past year. The target trial will be sequentially emulated (ie, eligibility assessed) every month in the database. Patients will be classified at baseline of each sequential trial in the intervention arm (deintensification of HDs: decrease of ≥50% in the total dose of HDs, including complete cessation) or control arm (no deintensification of HDs). The pooled dataset for all sequential emulated trials will be analysed. The primary outcome will be time to first occurrence of hospital admission or death, within 3 months. Secondary outcomes will be hospitalisation, death, appropriateness of glycaemic control and occurrence of HbA1c >75 mmol/mol within 1 year. Participants will be followed from baseline to 12 months after randomisation, administrative censoring, or death, whichever occurs first. A pooled logistic regression will be used to estimate the treatment effect on the incidence of the outcomes.

DISSEMINATION AND ETHICS

No ethical approval is needed for using retrospectively this fully anonymised database. The results will be disseminated during conferences and through publications in scientific journals.

Deprescribing research in nursing home residents using routinely collected healthcare data: a conceptual framework

BACKGROUND

Efforts are needed to strengthen evidence and guidance for appropriate deprescribing for older nursing home (NH) residents, who are disproportionately affected by polypharmacy and inappropriate prescribing. Given the challenges of conducting randomized drug withdrawal studies in this population, data from observational studies of routinely collected healthcare data can be used to identify patients who are apparent candidates for deprescribing and evaluate subsequent health outcomes. To improve the design and interpretation of observational studies examining determinants, risks, and benefits of deprescribing specific medications in older NH residents, we sought to propose a conceptual framework of the determinants of deprescribing in older NH residents.

METHODS

We conducted a scoping review of observational studies examining patterns and potential determinants of discontinuing or de-intensifying (i.e., reducing) medications for NH residents. We searched PubMed through September 2021 and included studies meeting the following criteria: conducted among adults aged 65 + in the NH setting; (2) observational study designs; (3) discontinuation or de-intensification as the primary outcome with key determinants as independent variables. We conceptualized deprescribing as a behavior through a social-ecological lens, potentially influenced by factors at the intrapersonal, interpersonal, organizational, community, and policy levels.

RESULTS

Our search in PubMed identified 250 potentially relevant studies published through September 2021. A total of 14 studies were identified for inclusion and were subsequently synthesized to identify and group determinants of deprescribing into domains spanning the five core social-ecological levels. Our resulting framework acknowledges that deprescribing is strongly influenced by intrapersonal, patient-level clinical factors that modify the expected benefits and risks of deprescribing, including index condition attributes (e.g., disease severity), attributes of the medication being considered for deprescribing, co-prescribed medications, and prognostic factors. It also incorporates the hierarchical influences of interpersonal differences relating to healthcare providers and family caregivers, NH facility and health system organizational structures, community trends and norms, and finally healthcare policies.

CONCLUSIONS

Our proposed framework will serve as a useful tool for future studies seeking to use routinely collected healthcare data sources and observational study designs to evaluate determinants, risks, and benefits of deprescribing for older NH residents.

Antihypertensive Deprescribing in Older Adults: a Practical Guide

PURPOSE OF REVIEW

To summarise evidence on both appropriate and inappropriate antihypertensive drug withdrawal.

RECENT FINDINGS

Deprescribing should be attempted in the following steps: (1) identify patients with several comorbidities and significant functional decline, i.e. people at higher risk for negative outcomes related to polypharmacy and lower blood pressure; (2) check blood pressure; (3) identify candidate drugs for deprescribing; (4) withdraw medications at 4-week intervals; (5) monitor blood pressure and check for adverse events. Although evidence is accumulating regarding short-term outcomes of antihypertensive deprescribing, long-term effects remain unclear. The limited evidence for antihypertensive deprescribing means that it should not be routinely attempted, unless in response to specific adverse events or following discussions between physicians and patients about the uncertain benefits and harms of the treatment.

PERSPECTIVES

Clinical controlled trials are needed to examine the long-term effects of deprescribing in older subjects, especially in those with comorbidities, and significant functional decline.

Aspirin and statin therapy for primary prevention of cardiovascular disease in older adults

The value of primary preventative therapies for cardiovascular disease (CVD) in older adults (age ≥75 years) is less certain than in younger patients. There is a lack of quality evidence in older adults due to underenrolment in pivotal trials. While aspirin is no longer recommended for routine use in primary prevention of CVD in older adults, statins may be efficacious. However, it is unclear which patient subgroups may benefit most, and guidelines differ between expert panels. Three relevant geriatric conditions (cognitive impairment, functional impairment and polypharmacy) may influence therapeutic decision making; for example, baseline frailty may affect statin efficacy, and some have advocated for deprescription in this scenario. Evidence regarding statins and incident functional decline are mixed, and vigilance for adverse effects is important, especially in the setting of polypharmacy. However, aspirin has not been shown to affect incident cognitive or functional decline, and its lack of efficacy extends to patients with baseline cognitive impairment or frailty. Ultimately, the utility of primary preventative therapies for CVD in older adults depends on potential lifetime benefit. Rather than basing treatment decisions on absolute risk alone, consideration of comorbidities, polypharmacy and life expectancy should play a significant role in decision making. Coronary calcium score and new tools for risk stratification validated in older adults that account for the competing risk of death may aid in evaluating potential benefits. Given the complexity of therapeutic decisions in this context, shared decision making provides an important framework.