Deprescribing: What do we know, and where to next?

Antimicrobial stewardship and education in optometry

CLINICAL RELEVANCE

Antimicrobial stewardship aims to improve how antibiotics are prescribed by clinicians and used by patients, to ensure safe appropriate use, and to prevent and contain antimicrobial resistance.

BACKGROUND

Australian optometrists can prescribe a range of antimicrobial agents, but to what extent they consider antimicrobial stewardship is not known. This study evaluated what final-year optometry students and optometrists understood about antimicrobial stewardship in eye care and considered relevance to oral prescribing and education.

METHODS

A knowledge, attitude, and practice (KAP) questionnaire was developed comprising four sections: i) demographic questions, ii) 10 multiple choice questions regarding Knowledge about antimicrobial agents and likely pathogens, diagnosis, treatment, and preventing resistance, iii) 10 Likert rating scale questions about thoughts and Attitudes, iv) mix of question types (5× MCQ: course of action, 16 Likert scale: confidence) related to Practice (diagnosis, management, and prescribing). Descriptive analyses were conducted (medians, mean±SD, and distributions).

RESULTS

Thirteen students and 36 optometrists completed the survey. Both groups had a good understanding of microbial resistance and antibiotic prescribing for ocular conditions; average knowledge scores were 9.2 ± 0.7 and 8.7 ± 1.1 for students and practitioners, respectively. Scores were neutral to agree for questions related to the need for more educational programs. The answers of practice-related MCQs had a dichotomy of answers indicating a diversity of opinion, as can be the case in practice. Average total practice confidence scores were approximately 57/80 for students and 68/80 for optometrists. Optometrists and students were very confident in their ability to conduct an appropriate case history and use their knowledge and clinical skills, including slit lamp anterior eye assessment. The lowest confidence scores were for conducting microbial testing, i.e. taking swabs for pathology.

CONCLUSION

Student and optometrist knowledge, attitudes, and practice around antimicrobial stewardship were high and in line with other health professions globally. There is scope for increased stewardship training.

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.

Deprescribing for nursing home residents with limited life expectancy: A qualitative study to identify barriers and enablers for healthcare professionals

Nursing home residents with limited life expectancy often take many medications eligible to deprescribing. Deprescribing is crucial but not yet routinely implemented. Therefore the aim of this study was to explore healthcare professionals (HCPs) barriers to and enablers for deprescribing and to identify theoretical domains for behavior change to be included into future interventions. A qualitative descriptive study using semi-structured interviews was conducted among 28 HCPs working in Belgian nursing homes. The data were analysed inductively using thematic analysis followed by mapping barriers and enablers to theoretical domain framework (TDF), and linking the domains to behavioral change techniques (BCTs). We identified multifaceted barriers and enablers across six themes: healthcare system and policy factors, resource- and organization-level factors, professional role and competency factors, interprofessional collaboration and communication factors, attitudes and perceptions towards deprescribing, and triadic dynamics in deprescribing. These barriers and enablers were mapped to 13 of the 14 TDF domains.

Deprescribing interventions in older adults: An overview of systematic reviews

OBJECTIVE

The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults.

METHODS

11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2).

RESULTS

We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment.

CONCLUSION

Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178860.

Assessing the Efficacy of the ARMOR Tool-Based Deprescribing Intervention for Fall Risk Reduction in Older Patients Taking Fall Risk-Increasing Drugs (DeFRID Trial): Protocol for a Randomized Controlled Trial

BACKGROUND

Falls in older patients can lead to serious health complications and increased health care costs. Fall risk-increasing drugs (FRIDs) are a group of drugs that may induce falls or increase the tendency to fall (ie, fall risk). Deprescribing is the process of withdrawal from an inappropriate medication, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes.

OBJECTIVE

This study aims to assess the effectiveness of a deprescribing intervention based on the Assess, Review, Minimize, Optimize, and Reassess (ARMOR) tool in reducing the risk of falls in older patients and evaluate the cost-effectiveness of deprescribing FRIDs.

METHODS

This is an open-label, parallel-group randomized controlled academic trial. Individuals aged 60-80 years who are currently taking 5 or more prescribed drugs, including at least 1 FRID, will be recruited. Demographic data, medical conditions, medication lists, orthostatic hypotension, and fall history details will be collected. Fall concern will be assessed using the Fall Efficacy Scale, and fall risk will be assessed by the Timed Up and Go test and Tinetti Performance-Oriented Mobility Assessment tool. In this study, all treating physicians will be randomized using a stratified randomization method based on seniority. Randomized physicians will do deprescribing with the ARMOR tool for patients on FRIDs. Participants will maintain diaries, and monthly phone follow-ups will be undertaken to monitor falls and adverse events. Physical assessments will be performed to evaluate fall risk every 3 months for a year. The rationality of prescription drugs will be evaluated using the World Health Organization's core indicators.

RESULTS

The study received a grant from the Indian Council of Medical Research-Safe and Rational Use of Medicine in October 2023. The study is scheduled to commence in April 2024 and conclude by 2026. Efficacy will be measured by fall frequency and changes in fall risk scores. Cost-effectiveness analysis will also include the incremental cost-effectiveness ratio calculation. Adverse events related to deprescription will be recorded.

CONCLUSIONS

This trial will provide essential insights into the efficacy of the ARMOR tool in reducing falls among the geriatric population who are taking FRIDs. Additionally, it will provide valuable information on the cost-effectiveness of deprescribing practices, offering significant implications for improving the well-being of older patients and optimizing health care resource allocation. The findings from this study will be pertinent for health care professionals, policy makers, and researchers focused on geriatric care and fall prevention strategies.

TRIAL REGISTRATION

Clinical Trials Registry - India CTRI/2023/12/060516; https://ctri.nic.in/Clinicaltrials/pubview2.php.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55638.

Development and validation of search filters to retrieve medication discontinuation articles in Medline and Embase

BACKGROUND

Medication discontinuation studies explore the outcomes of stopping a medication compared to continuing it. Comprehensively identifying medication discontinuation articles in bibliographic databases remains challenging due to variability in terminology.

OBJECTIVES

To develop and validate search filters to retrieve medication discontinuation articles in Medline and Embase.

METHODS

We identified medication discontinuation articles in a convenience sample of systematic reviews. We used primary articles to create two reference sets for Medline and Embase, respectively. The reference sets were equally divided by randomization in development sets and validation sets. Terms relevant for discontinuation were identified by term frequency analysis in development sets and combined to develop two search filters that maximized relative recalls. The filters were validated against validation sets. Relative recalls were calculated with their 95% confidences intervals (95% CI).

RESULTS

We included 316 articles for Medline and 407 articles for Embase, from 15 systematic reviews. The Medline optimized search filter combined 7 terms. The Embase optimized search filter combined 8 terms. The relative recalls were respectively 92% (95% CI: 87-96) and 91% (95% CI: 86-94).

CONCLUSIONS

We developed two search filters for retrieving medication discontinuation articles in Medline and Embase. Further research is needed to estimate precision and specificity of the filters.

Deprescribing: An umbrella review

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Measuring Quality of Life in Deprescribing Trials: A Scoping Review

BACKGROUND

Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions.

OBJECTIVE

We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials.

METHODS

We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist.

RESULTS

We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear.

CONCLUSIONS

Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research.

PROTOCOL REGISTRATION

Open Science Framework: osf.io/aez6w.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Deprescribing in a multimorbid older adult: A case vignette study among community pharmacists and primary care physicians

Collaborative deprescribing can include pharmacists' medication review with identification and suggestion of potential deprescribing targets to physicians. Case vignettes can be a valuable method for researching variations in clinical decision making, especially in settings unaccustomed to newer clinical approaches such as deprescribing. This study aimed to explore if pharmacists can identify deprescribing targets and if physicians would accept pharmacist's deprescribing rationales. A cross-sectional study was performed using an online case vignette based on a real-life elderly patient. Pharmacists were asked to indicate which medicines they would recommend deprescribing, alongside a rationale. Physicians were asked to state their acceptance of the proposed pharmacist's deprescribing suggestion. Pharmacists gave 1275 deprescribing rationales, and most were given for deprescribing opioids, NSAID and diuretics. Physicians would accept rationales to deprescribe a median of 10 medicines, while pharmacist would recommend deprescribing a median of six medicines. Most difference lays in deprescribing of preventative medicines. Healthcare providers share agreement on deprescribing targets, but pharmacists show hesitancies in making recommendations that could hamper potential collaboration. Action is needed to improve pharmacists' skills in recognizing deprescribing targets and confidence in making suggestions, which could lead to opening of possibilities for joint patient care.

Revisiting systematic reviews on deprescribing trials to better inform future practice and research

Deprescribing aims to address the problem of medication overuse in older adults. There has been an increasing number of systematic reviews of 'deprescribing'. We aimed to describe the categories of trials included in recent systematic reviews, and to make recommendations for future research. We categorized 122 trials included in eight recent deprescribing systematic reviews into: discontinuation, deprescribing implementation, medication optimisation (including medication initiation) and non-initiation trials. We identified heterogeneity and inconsistency in the categories of trials included in deprescribing systematic reviews. For example, 39 trials (32.0%) involved medication initiation in addition to the deprescribing component. It is now time for international researchers to develop and validate terminology used for trials involving discontinuation/deprescribing of medications, and to provide recommendations for evidence synthesis that will better inform future research, and translation into practice and policy.

Translation, cultural adaptation and validation of the revised patients' attitudes towards deprescribing (rPATD) questionnaire in Romanian older adults

BACKGROUND

Deprescribing is part of ensuring appropriate medication use and may reduce medication-related harm. Capturing the beliefs and attitudes of patients towards deprescribing by using a validated tool may support optimizing medication use in practice.

OBJECTIVES

To translate, culturally adapt and validate the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in Romanian and to investigate the attitudes and beliefs of older adults towards deprescribing.

METHODS

The rPATD questionnaire was translated using forward-backward translation into Romanian and culturally adapted. The psychometric properties were evaluated in older adults ≥65 years of age. Structural validity was assessed by item load on factors using an exploratory factor analysis (EFA) which was compared to the original English version and the internal consistency by Cronbach's alpha. Construct validity was evaluated by calculating the Spearman's rank correlation coefficients between the factor scores obtained using the revised version of the Romanian rPATD and scores on the Beliefs about Medicines Questionnaire (BMQ) Specific Concerns Romanian version. Floor and ceiling effect were also examined.

RESULTS

We translated the questionnaire and administered it to 224 participants (median age 72 years [interquartile range: 68.0; 77.0]). In the EFA individual items loaded onto 4 factors, grouped similarly to the English version (Involvement, Burden, Appropriateness, Concerns about Stopping factors). Two items from each of the Involvement and Appropriateness factors were removed to improve factor loading and avoid cross-loading. The Cronbach's alpha values for the 4 factors ranged between 0.522 and 0.773. The scores for Burden and Concerns about Stopping factors were found to be positively correlated with BMQ Specific Concerns score. We identified a ceiling effect for one of the four factors (Involvement) and no floor effects.

CONCLUSIONS

The Romanian rPATD was validated in 4 factor structure similar to the original English questionnaire. The Romanian version of the questionnaire may support the health care professionals in Romania to initiate and support patient-centered deprescribing.

Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial

Background

Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults.

Methods

This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires.

Discussion

This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways.

Clinical trial registration

ClinicalTrials.gov, identifier, NCT05765656.

Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review

BACKGROUND

Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations.

METHODS

We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations.

RESULTS

Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes.

CONCLUSIONS

This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.

Development and validation of search filters to identify articles on deprescribing in Medline and Embase

Background

Deprescribing literature has been increasing rapidly. Our aim was to develop and validate search filters to identify articles on deprescribing in Medline via PubMed and in Embase via Embase.com.

Methods

Articles published from 2011 to 2020 in a core set of eight journals (covering fields of interest for deprescribing, such as geriatrics, pharmacology and primary care) formed a reference set. Each article was screened independently in duplicate and classified as relevant or non-relevant to deprescribing. Relevant terms were identified by term frequency analysis in a 70% subset of the reference set. Selected title and abstract terms, MeSH terms and Emtree terms were combined to develop two highly sensitive filters for Medline via Pubmed and Embase via Embase.com. The filters were validated against the remaining 30% of the reference set. Sensitivity, specificity and precision were calculated with their 95% confidence intervals (95% CI).

Results

A total of 23,741 articles were aggregated in the reference set, and 224 were classified as relevant to deprescribing. A total of 34 terms and 4 MeSH terms were identified to develop the Medline search filter. A total of 27 terms and 6 Emtree terms were identified to develop the Embase search filter. The sensitivity was 92% (95% CI: 83–97%) in Medline via Pubmed and 91% (95% CI: 82–96%) in Embase via Embase.com.

Conclusions

These are the first deprescribing search filters that have been developed objectively and validated. These filters can be used in search strategies for future deprescribing reviews. Further prospective studies are needed to assess their effectiveness and efficiency when used in systematic reviews.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01515-x.