Deprescribing: a primary care perspective

Post-discharge pharmacotherapy in people with atrial fibrillation hospitalized for acute myocardial infarction: an Australian cohort study 2018-22

BACKGROUND

Dual antiplatelet therapy with P2Y12 inhibitors (P2Y12i) and aspirin following acute myocardial infarction (AMI) prevents future ischaemic events. People with atrial fibrillation (AF) also require oral anticoagulants (OAC), increasing bleeding risk. Guidelines recommend post-discharge prescribing of direct OAC with clopidogrel and discontinuation of P2Y12i after 12 months, but little is known about use in clinical practice.

AIM

To describe post-discharge use of OACs and P2Y12i in people with AF and a history of OAC use hospitalized for AMI.

METHODS AND RESULTS

We identified 1330 people hospitalized for AMI with a diagnosis of AF and history of OAC use in New South Wales, Australia, July 2018-June 2020. We identified three aspects of post-discharge antithrombotic medicine use with possible safety implications: (1) not being dispensed OACs; (2) dispensing OAC and P2Y12i combinations associated with increased bleeding (involving warfarin, ticagrelor, or prasugrel); and (3) P2Y12i use longer than 12 months.After discharge, 74.3% of people were dispensed an OAC, 45.4% were dispensed a P2Y12i, and 35.8% were dispensed both. People with comorbid heart failure or cancer were less likely to receive OACs. Only 11.2% of people who dispensed both an OAC and P2Y12i received combinations associated with increased bleeding; this was more common among people with chronic kidney disease or prior warfarin or statin use. A total of 44.6% of people dispensed both medicines continued P2Y12i for over 12 months; this was more common in people who received a revascularization or lived in areas of social disadvantage.

CONCLUSION

We identified potential gaps in pharmacotherapy, including underuse of recommended therapies at discharge, use of combinations associated with increased bleeding, and P2Y12i use beyond 12 months. Prescribing vigilance across both hospital and community care is required.

Development of a complex multidisciplinary medication review and deprescribing intervention in primary care for older people living with frailty and polypharmacy

INTRODUCTION

Reducing polypharmacy and overprescribing in older people living with frailty is challenging. Evidence suggests that this could be facilitated by structured medication review (SMR) and deprescribing processes involving the multidisciplinary team (MDT). This study aimed to develop an MDT SMR and deprescribing intervention in primary care for older people living with frailty.

METHODS

Intervention development was informed by the Medical Research Council framework for complex intervention and behaviour change and implementation theories. Intervention planning included: 1) a realist review of 28 papers that identified 33 context-mechanism-outcome configurations for successful MDT SMR and deprescribing in primary care, 2) a qualitative study with 26 healthcare professionals (HCPs), 13 older people with polypharmacy and their informal carers. The intervention's guiding principles were developed and intervention functions proposed, discussed and refined through an iterative process in four online co-design stakeholder workshops.

RESULTS

The final version of the complex intervention consisted of five components: 1) Proactive identification of patients living with frailty and polypharmacy for targeted SMR using routinely collected primary care data; 2) HCPs' preparation using an evidence-based deprescribing tool to identify and prioritise high-risk medications for deprescribing; 3) Preparing patients and carers using a leaflet sent prior to SMR explaining the purpose of SMR and reasons for potentially stopping or changing medications; 4) Conducting a person-centred SMR face-to-face or by phone, tailored to patient/carer needs, involving other MDT members based on their expertise; 5) Tailored follow-up plans allowing continuity of care and highlighting signs and symptoms for patients and carers to monitor, and arranging follow-up through text, phone or face-to-face appointment.

CONCLUSION

A complex MDT SMR and deprescribing intervention for older people living with frailty was developed to address multiple challenges to deprescribing. The use of rigorous methods and behaviour and implementation theories potentially maximises the intervention's feasibility, acceptability and successful implementation.

Factors Influencing General Practitioners' Deprescribing Decisions for Older Adults, with Insights into Frailty: a Qualitative Study in Greek Primary Care

INTRODUCTION

Polypharmacy is increasing among older individuals worldwide. Deprescribing has been suggested as a strategy to reduce polypharmacy, but it has had a limited impact.

OBJECTIVE

This study investigated the facilitators and barriers to deprescribing in older adults, as perceived by primary care general practitioners, focusing particularly on factors influencing deprescribing in frail individuals.

METHODS

A qualitative approach was employed and semistructured interviews were conducted between 9 April and 29 May 2024 with a sample of 30 general practitioners working in primary care facilities in Crete, Greece. The interviews were recorded and transcribed verbatim. Thematic analysis was performed on the basis of the Theoretical Domains Framework.

RESULTS

Several barriers to deprescribing were revealed, including a lack of expertise and motivation, inadequate communication skills, time constraints, and negative beliefs toward deprescribing held by physicians and patients. The lack of an established role for general practitioners in primary care, the absence of a national initiative targeting polypharmacy, and the influence of pharmacists and pharmaceutical representatives were highlighted as challenges. The identified facilitators included the incorporation of deprescribing recommendations and considerations for frail patients into guidelines, fostering a strong doctor-patient relationship, promoting shared decision-making, facilitating effective collaboration with caregivers, and utilizing nonpharmacological therapy.

CONCLUSIONS

General practitioners encounter both barriers and facilitators when making deprescribing decisions for older adults, particularly those with frailty syndrome. Researchers and policymakers can use the findings of this research to guide future interventions and promote successful deprescribing practices.

Exploring the need for a clinical decision support system for deprescribing - A qualitative interview study

Background

Deprescribing (i.e., the process of discontinuing an inappropriate medication) requires time, knowledge, and care, but there is a lack of education, support, and guidelines for this important clinical task. A clinical decision support system (CDSS) aims to influence the quality of care by combining structured medical knowledge with patient-specific information to generate recommendations.

Objective

The objective was to examine the need to develop a CDSS for drug deprescribing. Furthermore, this study aimed to examine the obstacles to deprescribing and potential users' requirements for a CDSS for deprescribing.

Methods

The qualitative design consisted of semistructured interviews with physicians (n = 10) in Sweden from different disciplines, including geriatrics, primary care and internal medicine. The interviews were conducted using a predefined guide containing multiple questions about any challenges related to deprescribing and the perceived need for a CDSS. A qualitative content analysis was performed to analyse the empirical data.

Results

The interviews provided several aspects of the difficulty of deprescribing medicines. The structure and usability of the CDSS knowledge database in clinical practice needs to be ensured from the outset. Physicians needs fast, simple and up-to-date information filtered, summarized and synthesized from reliable sources. The information should preferably be integrated into pre-existing electronic health record.

Conclusion

There is a need to develop a CDSS for deprescribing. There is little, if any, guidelines or support for deprescribing, which is regarded as a large obstacle. The current findings contribute to further knowledge regarding the perspective of physicians when deprescribing medication.

Collaborative discussions between GPs and pharmacists to optimise patient medication: a qualitative study within a UK primary care clinical trial

BACKGROUND

There has been significant investment in pharmacists working in UK general practice to improve the effective and safe use of medicines. However, evidence of how to optimise collaboration between GPs and pharmacists in the context of polypharmacy (multiple medication) is lacking.

AIM

To explore GP and pharmacist views and experiences of in-person, interprofessional collaborative discussions (IPCDs) as part of a complex intervention to optimise medication use for patients with polypharmacy in general practice.

DESIGN AND SETTING

A mixed-method process evaluation embedded within the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial conducted in Bristol and the West Midlands, between February 2021 and September 2023.

METHOD

Audio-recordings of IPCDs between GPs and pharmacists, along with individual semi-structured interviews to explore their reflections on these discussions, were used. All recordings were transcribed verbatim and analysed thematically.

RESULTS

A total of 14 practices took part in the process evaluation from February 2022 to September 2023; 17 IPCD meetings were audio-recorded, discussing 30 patients (range 1-6 patients per meeting). In all, six GPs and 13 pharmacists were interviewed. The IPCD was highly valued by GPs and pharmacists who described benefits, including: strengthening their working relationship; gaining in confidence to manage more complex patients; and learning from each other. It was often challenging, however, to find time for the IPCDs.

CONCLUSION

The model of IPCD used in this study provided protected time for GPs and pharmacists to work together to deliver whole-patient care, with both professions finding this beneficial. Protected time for interprofessional liaison and collaboration, and structured interventions may facilitate improved patient care.

Physician perspectives on statin continuation and discontinuation in older adults in primary cardiovascular prevention: a qualitative methods study

OBJECTIVES

In the context of limited evidence on statin use in primary cardiovascular prevention in older adults, we assessed physician perspectives on decision-making about statin continuation or discontinuation in this population.

DESIGN

Qualitative descriptive approach including four focus groups. Inductive and deductive thematic analysis.

SETTING AND PARTICIPANTS

18 physicians including two neurologists, three cardiologists, seven hospital internists and six primary care providers (PCPs) recruited at a hospital and primary care practices in the area of Bern in Switzerland.

RESULTS

Concerning knowledge about statins in older adults, physicians reported defining if a patient is treated for primary or secondary prevention as challenging and that lack of evidence makes the decision to continue or discontinue the statin difficult. In terms of beliefs, fear of a possible rebound effect after statin discontinuation was reported. Regarding decision-making, physicians mentioned that statin discontinuation or continuation should be a shared decision between the patient and the physician. Concerning the professional role, environmental context and resources, the PCP office was identified as the ideal setting to discuss discontinuation, as all necessary information is available and PCPs have a longer relationship with the patients, thus facilitating a shared decision. Discontinuation of a chronic medication was perceived as difficult in general. Furthermore, PCPs noticed a possible negative impact on patient-physician relationship as some patients felt not being worth it, given up or undertreated if the statin was discontinued.

CONCLUSIONS

This study highlights the challenges of statin continuation and discontinuation in older patients and the crucial role of PCPs in situations with unclear evidence for a medication, where shared decision-making between physicians and patients is important. More evidence forming the background for a decision aid would be helpful.

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life

INTRODUCTION

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing.

OBJECTIVE

This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life.

METHODS

We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions.

RESULTS

Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing.

CONCLUSIONS

Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Evaluation of deprescription by general practitioners in elderly people with different levels of dependence: cross-sectional study

BACKGROUND

Polypharmacy is easily achieved in elderly patients with multimorbidity and it is associated with a higher risk of potentially inappropriate medication use and worse health outcomes. Studies have shown that deprescription is safe, however, some barriers have been identified. The aim of this study was to analyse Portuguese General Practitioners (GP) deprescription's attitudes using clinical vignettes.

METHODS

Cross-sectional study using an online survey with 3 sections: demographic and professional characterization; two clinical vignettes with an elderly patient with multimorbidity and polypharmacy in which the dependency level varies; barriers and factors influencing deprescription. Frequencies, means, and standard deviations were calculated to describe the GPs. Analysis of the deprescription attitude, globally and for each drug, for each clinical vignette applying the McNeemar's test.

RESULTS

A sample of 396 GP was obtained with a mean age of 38 years, most of them female. A statistically significant difference (p < 0.01) was observed in deprescribing according to the patient dependency level, with more GPs (80.4% versus 75.3%) deprescribing in the most dependent patient. A statistically significant difference was found for all drugs except for antihypertensive drugs. All medications were deprescribed more often in dependent patients except for anti-dementia drugs. More than 70% of the participants considered life expectancy and quality of life as "very important" factors for deprescription and more than 90% classified the existence of guidelines and the risks and benefits of medication as "very important" or "important". In the open question, the factors most reported by the GP were those related to the patient (52,9%).

CONCLUSIONS

This is the largest study on this topic carried out in Portugal using clinical vignettes, with a representative sample of Portuguese GP. The level of dependence significatively influenced the deprescription attitude of Portuguese GPs. The majority of the GPs classified the quality of life, life expectancies, potential negative effects and the existence of guidelines as "very important" or "important" while deprescribing. It is important to develop and test deprescribing in real life studies to analyze if these attitudes are the same in daily practice.

Unlocking Deprescribing Potential in Nursing Homes: Insights from a Focus Group Study with Healthcare Professionals

BACKGROUND

The nursing home population is characterized by multimorbidity and disabilities, which often result in extensive prescription of medication and subsequent polypharmacy. Deprescribing, a planned and supervised process of dose reduction or total cessation of medication, is a solution to combat this.

OBJECTIVE

This study aimed to identify barriers and enablers of deprescribing as experienced by nursing home physicians (NHPs) and collaborating pharmacists in the specific nursing home setting.

METHODS

This qualitative study utilized a semi-structured interview format with two focus groups consisting of a mix of NHPs and pharmacists. Directed content analysis was performed based on the Theoretical Domains Framework, a validated framework for understanding determinants of behavior change among health care professionals.

RESULTS

Sixteen health care professionals participated in two focus groups, including 13 NHPs and three pharmacists. The participating NHPs and pharmacists believed that deprescribing is a valuable process with enablers, such as multidisciplinary collaboration, good communication with patients and family, and involvement of the nursing staff. NHPs and pharmacists view deprescribing as a core task and feel assured in their ability to carry it out successfully. However, they also noted barriers: deprescribing is time-consuming; communication with residents, their relatives or medical specialists is difficult; and electronic patient systems often do not adequately support it.

CONCLUSIONS

This study provides insight into the various barriers and enablers faced by NHPs and pharmacists when deprescribing in nursing homes. Specific for this population, deprescribing barriers focus on communication (with residents and their relatives, and also with medical specialists) and resources, while knowledge and expertise are mentioned as enablers.

Understanding Australian general practice patients' decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach

OBJECTIVES

To evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying the mechanisms of the approach and (3) describing what contexts are associated with antidepressant tapering.

DESIGN

This mixed methods study was informed by the principles of realist evaluation and was conducted in the first 3 months of participation in the WiserAD randomised control trial.

SETTING

General practice, Victoria, Australia.

PARTICIPANTS

13 antidepressant users from general practice participating in the WiserAD trial for antidepressant deprescribing.

INTERVENTION

A patient-facing, web-based structured support tool that consists of a personalised tapering schedule, an action plan for managing withdrawal symptoms, a daily mood, sleep and activity tracker and mental health nurse support.

PRIMARY/SECONDARY OUTCOME MEASURES

The outcomes of the study were revealed on data analysis as per a realist evaluation approach which tests and refines an initial programme theory.

RESULTS

The contexts of learnt coping skills, knowledge and perceptions of antidepressants and feeling well were evident. Outcomes were intention to commence, initiation of deprescribing and successful completion of deprescribing. Key mechanisms for antidepressant deprescribing were (1) initiation of the deprescribing discussion; (2) patient self-efficacy; (3) provision of structured guidance; (4) coaching; (5) mood, sleep and activity tracking and (6) feelings of safety during the tapering period.

CONCLUSIONS

The WiserAD approach to antidepressant deprescribing supported participants to commence and/or complete tapering. The refined programme theory presents the WiserAD pragmatic framework for the application of antidepressant deprescribing in clinical practice.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT05355025; ACTRN12622000567729; ISRCTN11562922; Pre-results.

Deprescribing, shared decision-making, and older people: perspectives in primary care

Polypharmacy is an issue that affects many people, especially older adults, and could result in negative outcomes such as lower medication adherence and an increase in the likelihood of adverse drug reactions. Deprescribing is a possible solution to mitigating this issue. Examining polypharmacy and deprescribing in primary care settings is important as it could help older adults living in the community and their relatives by lowering their treatment burden and medication cost. Some guidelines have been developed to help with the deprescribing process; however, these guidelines are not applicable to all patients and situations. Thus, the deprescribing process needs to be based mainly on the patient's current situations, preferences, and values and this could be achieved using shared decision-making. However, some barriers slow down the process to deprescribe in primary care settings and measures should be taken to overcome these barriers. This review aims to examine the current situation of deprescribing, especially in primary care settings, and how SDM can be used to optimize the deprescribing process. To achieve this an illustration using one prominent model in SDM and one prominent model in deprescribing will be presented to showcase how SDM can be used in the deprescribing process.

Medication prescription profile and hospital admission related to medication administration errors in England and Wales: an ecological study

OBJECTIVE

To explore the correlation between prescribing rate of medications and hospital admissions related to medications administration errors in England and Wales during the time from 1999 to 2020.

DESIGN

An ecological study.

SETTING

A population-based study using hospital admission data that are publicly available in the UK. Data in this study were extracted from the Hospital Episode Statistics database in England and the Patient Episode Database in Wales from Wales. The Prescription Cost Analysis database was used to extract the prescription data.

PARTICIPANTS

Patients who were hospitalised all National Health Service (NHS) trusts and any independent sector funded by NHS trusts.

PRIMARY OUTCOME MEASURE

Hospitalisation rates related to medication administration errors and its associated prescriptions.

RESULTS

The annual rate of hospital admissions related to medication administration errors increased by 32.0% (from 184.21 (95% CI 183.0 to 185.4) in 1999 to 243.18 (95% CI 241.9 to 244.4) in 2020 per 100 000 persons. The most common three indications of hospital admissions were T39 (non-opioid analgesics, antipyretics and antirheumatics), T43 (psychotropic drugs), T42 (antiepileptic, sedative-hypnotic and antiparkinsonism drugs). The age group 15-59 years had the highest number of hospital admissions (83.4%). Women contributed to 59.1% of the total number of hospital admissions. Admission rate among men increased by 16.7%. Among women, the admission rate increased by 44.6%.

CONCLUSION

Admission rates due to medication administration errors increased markedly in the past decade. This increase was correlated with an increase in the prescription rate of several therapeutic classes. Patients taking non-opioid analgesics, antipyretics and antirheumatics, psychiatric medications, antiepileptic, sedative-hypnotic and antiparkinsonism drugs should have their recommended (and administered) doses closely monitored. They should be followed up on a regular basis to ensure that they are taking their medications as prescribed.

What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis

BACKGROUND

A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people.

METHODS

A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care.

FINDINGS

A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with 'quick wins', offering deprescribing as 'drug holidays', and ensuring appropriate and tailored follow-up plans that allow continuity of care and management.

CONCLUSION

We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

Inappropriate proton-pump inhibitor prescribing in primary care - an observational study with quality circles

INTRODUCTION

Proton-pump inhibitors (PPIs) should be deprescribed when an indication is lacking or the dose is too high. Academic and media reports have tried to raise awareness and thereby reduce the inappropriate prescribing of PPIs. However, pharmacoepidemiologic studies have shown an unchanged frequency of such inappropriate prescribing over time. Little is known about whether or how general practitioners (GPs) adapt their prescribing practices once their awareness of inappropriate PPI prescribing has been raised.

OBJECTIVE

We aimed to investigate the prevalence of potentially inappropriate PPI prescribing (too high dose or no indication) in a consecutive sample of patients in Swiss primary care settings. Our goal was then to evaluate how GPs managed the patients with potentially inappropriate PPI prescribing over 12 months after flagging these patients.

METHODS

In this observational study, 11 GPs from the canton of Bern in Switzerland used their medical records to identify 20 patients who had been prescribed a PPI for ≥8 weeks and flagged potentially inappropriate PPI prescribing in their records. After 12 months, we asked the same GPs whether the PPI prescriptions of those patients had changed and, if so, how.

RESULTS

Of 1,376 patients consecutively screened, 206 (15%) had been prescribed a PPI for ≥8 weeks. Of these 206 patients, 85 (41%) had a potentially inappropriate PPI prescription. Of these 85 patients, 55 (65%) had no indication for PPI, and 30 (35%) had a too-high dose. After one year, only 29 (35%) of the 84 flagged potentially inappropriate PPIs were stopped or reduced. The most frequently mentioned reasons that deprescribing was not possible were a lack of discussion with the patient (no contact or no time), the presence of symptoms requiring the PPI, or the unwillingness of the patient to deprescribe.

CONCLUSION

In the Swiss primary care setting, the rate of potentially inappropriate PPI prescribing is high. Having GPs flag potentially inappropriate PPI prescribing did not result in PPI deprescribing in most patients over 12 months. Our findings suggest that more personalised and targeted interventions are necessary to successfully implement the deprescribing of potentially inappropriate PPIs. We see the need to co-design interventions with patients and providers and test behavioural change techniques to enable the deprescribing of inappropriate PPIs.

Recommendations on deprescribing of bisphosphonates in osteoporosis guidelines: a systematic review

PURPOSE

Advancing age, declining health status, and a shift in benefit/risk balance warrant judicious use of preventive medications in older persons, including consideration of deprescribing. Lack of guidance on deprescribing is a major barrier for prescribers to consider deprescribing in daily practice. The aim of this review was to evaluate to what extent osteoporosis guidelines include bisphosphonate deprescribing recommendations.

METHODOLOGY

We conducted a systematic review, searching PubMed, Embase, and grey literature. We included guidelines on treatment of osteoporosis with bisphosphonates. Two independent reviewers screened titles, abstracts, and full texts. Recommendations for deprescribing were extracted, and quality of guidelines were assessed.

RESULTS

Among 9345 references, 42 guidelines were included. A total of 32 (76%) guidelines included deprescribing recommendations: 29 (69%) guidelines included non-specific deprescribing recommendations framed as a drug holiday, of which 2 (5%) also included specific deprescribing recommendations based on individual health context (e.g. life expectancy, frailty, function, preferences/goals). Twenty-four (57%) guidelines included practical deprescribing recommendations, and 27 (64%) guidelines included recommendations for when deprescribing should not be considered.

CONCLUSION

Bisphosphonate deprescribing recommendations in osteoporosis guidelines were primarily framed as drug holidays, with limited guidance on how to make individualized deprescribing decisions based on individual health context. This suggests a need for additional focus on deprescribing in osteoporosis guidelines.

Weighing the necessities and concerns of deprescribing among older ambulatory patients and primary care trainees: a qualitative study

BACKGROUND

Deprescribing can be a challenging and complex process, particularly for early career doctors such as primary care trainees. To date, there is limited data from patients' and doctors' perspectives regarding the deprescribing of medications in older persons, particularly from developing countries. This study aimed to explore the necessities and concerns of deprescribing in older persons among older ambulatory patients and primary care trainees.

METHODS

A qualitative study was conducted among patients and primary care trainees (known henceforth as doctors). Patients aged ≥ 60 years, having ≥ 1 chronic disease and prescribed ≥ 5 medications and could communicate in either English or Malay were recruited. Doctors and patients were purposively sampled based on their stage of training as family medicine specialists and ethnicity, respectively. All interviews were audio-recorded and transcribed verbatim. A thematic approach was used to analyse data.

RESULTS

Twenty-four in-depth interviews (IDIs) with patients and four focus group discussions (FGDs) with 23 doctors were conducted. Four themes emerged: understanding the concept of deprescribing, the necessity to perform deprescribing, concerns regarding deprescribing and factors influencing deprescribing. Patients were receptive to the idea of deprescribing when the term was explained to them, whilst doctors had a good understanding of deprescribing. Both patients and doctors would deprescribe when the necessity outweighed their concerns. Factors that influenced deprescribing were doctor-patient rapport, health literacy among patients, external influences from carers and social media, and system challenges.

CONCLUSION

Deprescribing was deemed necessary by both patients and doctors when there was a reason to do so. However, both doctors and patients were afraid to deprescribe as they 'didn't want to rock the boat'. Early-career doctors were reluctant to deprescribe as they felt compelled to continue medications that were initiated by another specialist. Doctors requested more training on how to deprescribe medications.

Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care

BACKGROUND

Polypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management.

METHODS

We conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called 'higher risk' polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on 'moments of potentiation' and traced clinicians' shifting understandings of their practices.

RESULTS

Participants rarely referenced biomedical aspects of prescribing (eg, drug-drug interactions, 'Numbers Needed to Treat/Harm') focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients' medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete 'one-off' activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care.

CONCLUSIONS

Supporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship.

Deprescribing, Polypharmacy and Prescribing Cascades in Older People with Type 2 Diabetes: A Focused Review

Deprescribing is the process by which medications are reduced without compromising safety to the patient (Jude et al. in 2022 Diabetes Ther 13: 619–634, 2022). The purpose of this narrative review is to discuss deprescribing as a topic, firstly discussing the benefits and pitfalls to such pharmacological interventions along with the current barriers and enablers to such a controversial topic, and then discussing deprescribing with respect to preventive medications, namely those that reduce the long term impacts of a condition or disease. Research that has previously focused on reducing polypharmacy has highlighted the benefits of such interventions, including reduction of adverse reactions or complications, improved patient satisfaction and quality of life, and improved cost effectiveness and drug compliance. Some potential harms that have been highlighted include an increased number of complications, increased symptoms of previously dampened conditions, and negligible changes in patient satisfaction that have stressed the importance of this intervention being patient centred and individualized to each patient. The implementation of deprescribing processes could drastically change the way people think about deprescribing and could be extremely beneficial to older patients living with type 2 diabetes worldwide. Developments in preventive medication deprescribing could pave the way for this intervention to become more common place improving the quality of life in patient’s final years.

Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies

BACKGROUND

Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC.

METHODS

This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications.

RESULTS

Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs.

CONCLUSIONS

By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives.

TRIAL REGISTRATION

NCT04242186.

A pharmacist-led medication review service with a deprescribing focus guided by implementation science

Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65 years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.

Evaluation of a Pharmacist-Driven Ambulatory Aspirin Deprescribing Protocol

Background

Recent guidelines indicate that aspirin affords less cardiovascular protection and greater bleeding risks in adults aged > 70 years. Deprescribing potentially inappropriate medications is particularly important in older adults, as this population experiences a high risk of adverse effects and polypharmacy. Limited data are available regarding targeted aspirin deprescribing approaches by pharmacists. The objective of this study was to implement and evaluate the success and feasibility of a pharmacist-led aspirin deprescribing protocol for older adults in a primary care setting.

Observations

This prospective feasibility study in a US Department of Veterans Affairs ambulatory care pharmacy setting included patients aged ≥ 70 years with documented aspirin use. We reviewed 459 patient records and determined that 110 were eligible for deprescribing. A pharmacistinitiated telephone call was attempted for each eligible patient to discuss the risks and benefits of deprescribing aspirin. The primary outcome was the proportion of patients reached for whom aspirin was discontinued. Secondary outcomes included patient rationale for declining deprescribing and the time to complete the intervention. Of 94 patients reached, 45 (48%) agreed to aspirin deprescribing, 3 (3%) agreed to dose reduction, and 29 (31%) declined the intervention. An additional 17 (18%) had previously stopped aspirin, which led to a medication reconciliation intervention. Pharmacists spent about 2 minutes per record review and 12 minutes on each encounter, including documentation.

Conclusions

Implementing a pharmacist-driven aspirin deprescribing protocol in a primary care setting led to the discontinuation of inappropriate aspirin prescribing in nearly half of older adults contacted. The protocol was well accepted by collaborating physicians and feasible for pharmacists to implement, with potential for further dissemination across primary care settings.

Primary care clinicians' use of deprescribing recommendations: A mixed-methods study

OBJECTIVE

to explore the effects of a deprescribing intervention on primary care clinicians' medication-related communication.

METHODS

A clinical decision support tool provided clinicians in the intervention group with an individualized report regarding potentially inappropriate medications (PIMs), deintensification of diabetes and/or hypertension treatment, and poor adherence/cognition. Participants included 113 Veterans aged ≥ 65 prescribed ≥ 7 medications and their primary care clinicians. Encounters were recorded and analyzed.

RESULTS

Between 36% and 38% of intervention clinicians discussed PIMs and diabetes mellitus/hypertension deintensification and 94% discussed adherence. PIMs discussions referred to the report and prompted some medication changes. The diabetes mellitus/hypertension and adherence discussions were not prompted by the report but instead arose from enhanced medication reconciliation. Changes in diabetes mellitus/hypertension medications were not made out of overtreatment concerns. There was no deprescribing for nonadherence. Enhanced medication reconciliation also led to discussions about medications not in the report.

CONCLUSION

An individualized report regarding medication appropriateness prompted clinicians to perform a more thorough medication reconciliation and discuss PIMs. It did not prompt chronic care deintensification or deprescribing to enhance adherence.

PRACTICE IMPLICATIONS

Feedback reports can promote robust medication reconciliation in primary care. Changing clinician practice to achieve deprescribing in chronic disease management will be more challenging.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Continue or not to continue? Attitudes towards deprescribing among community-dwelling older adults in China

Background

Inappropriate prescribing of medications and polypharmacy among older adults are associated with a wide range of adverse outcomes. It is critical to understand the attitudes towards deprescribing—reducing the use of potentially inappropriate medications (PIMs)—among this vulnerable group. Such information is particularly lacking in low - and middle-income countries.

Methods

In this study, we examined Chinese community-dwelling older adults’ attitudes to deprescribing as well as individual-level correlates. Through the community-based health examination platform, we performed a cross-sectional study by personally interviews using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire (version for older adults) in two communities located in Suzhou, China. We recruited participants who were at least 65 years and had at least one chronic condition and one prescribed medication.

Results

We included 1,897 participants in the present study; the mean age was 73.8 years (SD = 6.2 years) and 1,023 (53.9%) were women. Most of older adults had one chronic disease (n = 1,364 [71.9%]) and took 1–2 regular drugs (n = 1,483 [78.2%]). Half of the participants (n = 947, 50%) indicated that they would be willing to stop taking one or more of their medicines if their doctor said it was possible, and 924 (48.7%) older adults wanted to cut down on the number of medications they were taking. We did not find individual level characteristics to be correlated to attitudes to deprescribing.

Conclusions

The proportions of participants’ willingness to deprescribing were much lower than what prior investigations among western populations reported. It is important to identify the factors that influence deprescribing and develop a patient-centered and practical deprescribing guideline that is suitable for Chinese older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03184-3.

Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study

BACKGROUND

Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians' baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians' (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios.

METHODS

As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients' expectations surrounding low-value prescribing.

RESULTS

We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients' well-being over satisfying their expectations.

CONCLUSIONS

When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.

Barriers and Enablers of Healthcare Providers to Deprescribe Cardiometabolic Medication in Older Patients: A Focus Group Study

Introduction

Benefits and risks of preventive medication change over time for ageing patients and deprescribing of medication may be needed. Deprescribing of cardiovascular and antidiabetic drugs can be challenging and is not widely implemented in daily practice.

Objective

The aim of this study was to identify barriers and enablers of deprescribing cardiometabolic medication as seen by healthcare providers (HCPs) of different disciplines, and to explore their views on their specific roles in the process of deprescribing.

Methods

Three focus groups with five general practitioners, eight pharmacists, three nurse practitioners, two geriatricians, and two elder care physicians were conducted in three cities in The Netherlands. Interviews were recorded and transcribed verbatim. Directed content analysis was performed on the basis of the Theoretical Domains Framework. Two researchers independently coded the data.

Results

Most HCPs agreed that deprescribing of cardiometabolic medication is relevant but that barriers include lack of evidence and expertise, negative beliefs and fears, poor communication and collaboration between HCPs, and lack of resources. Having a guideline was considered an enabler for the process of deprescribing of cardiometabolic medication. Some HCPs feared the consequences of discontinuing cardiovascular or antidiabetic medication, while others were not motivated to deprescribe when the patients experienced no problems with their medication. HCPs of all disciplines stated that adequate patient communication and involving the patients and relatives in the decision making enables deprescribing. Barriers to deprescribing included the use of medication initiated by specialists, the poor exchange of information, and the amount of time it takes to deprescribe cardiometabolic medication. The HCPs were uncertain about each other’s roles and responsibilities. A multidisciplinary approach including the pharmacist and nurse practitioner was seen as the best way to support the process of deprescribing and address barriers related to resources.

Conclusion

HCPs recognized the importance of deprescribing cardiometabolic medication as a medical decision that can only be made in close cooperation with the patient. To successfully accomplish the process of deprescribing they strongly recommended a multidisciplinary approach.

GP preferences for discussing statin deprescribing: a discrete choice experiment

BACKGROUND

Deprescribing (planned, supervised discontinuation) of statins may be considered in some older persons. This should be carefully discussed between patients and GPs.

METHODS

We examined GPs' preferences for discussing statin deprescribing by conducting a discrete choice experiment (DCE) sent to a stratified random sample of 500 Danish GPs. Attributes were discussion topics (goals of therapy, evidence on statin use in older persons, adverse effects, uncertainty), and levels were the depth of the discussion topics (none, brief, detailed). We used mixed logistic regression for analysis.

RESULTS

A total of 90 GPs (mean age 48, 54% female, mean 11 years in practice) completed the DCE. There was substantial variability in which topics GPs felt were most important to discuss; however, GPs generally preferred a brief discussion of topics to detailed ones. The most important discussion topic appeared to be goals of therapy. GPs felt a brief discussion of evidence was important but not a detailed one, while adverse effects and uncertainty were felt to be less important to discuss.

CONCLUSION

GPs prefer brief discussions on a range of topics when discussing statin deprescribing but have differing views on which topics are most important. For deprescribing communication tools to be useful to GPs in clinical practice, they may need to focus on brief coverage of the range of relevant topics. Future work should evaluate patient preferences, and opportunities for education and training for GPs on deprescribing communication.

Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist-led interdisciplinary intervention to improve medication safety in older hospitalized patients

WHAT IS KNOWN AND OBJECTIVE

The majority of hospitalized older patients experience medication-related problems (MRPs), and there is a call for interventions to solve MRPs and improve clinical outcomes like medical visits. The IMMENSE study is a randomized controlled trial investigating the impact of a pharmacist-led interdisciplinary intervention on emergency medical visits. Its multistep intervention is based on the integrated medicines management methodology and includes a follow-up step with primary care. This study aims to describe how the intervention in the IMMENSE study was delivered and its process outcomes.

METHODS

The study includes the 221 intervention patients in the per-protocol group of the IMMENSE study. Both intervention delivery, reasons for not performing interventions and process outcomes were registered daily by the study pharmacists in a Microsoft Access^® database. Process outcomes were medication discrepancies, MRPs and how the team solved these.

RESULTS AND DISCUSSION

A total of 121 (54.8%) patients received all intervention steps if appropriate. All patients received medication reconciliation (MedRec) and medication Review (MedRev) (step 1 and 2), while between 10% and 20% of patients were missed for medication list in discharge summary (step 3), patient counselling (step 4), or communication with general practitioner and nurse (step 5). A total of 437 discrepancies were identified in 159 (71.9%) patients during MedRec, and 1042 MRPs were identified in 209 (94.6%) patients during MedRev. Of these, 292 (66.8%) and 700 (67.2%), respectively, were communicated to and solved by the interdisciplinary team during the hospital stay.

WHAT IS NEW AND CONCLUSION

The fidelity of the single steps of the intervention was high even though only about half of the patients received all intervention steps. The impact of the intervention may be influenced by not implementing all steps in all patients, but the many discrepancies and MRPs identified and solved for the patients could explain a potential effect of the IMMENSE study.

Predictors and patterns of polypharmacy in chronic diseases in a middle-income country

Low and middle-income countries (LMIC) are increasingly affected by non-communicable diseases (NCDs), which overburden the health system. With the rising prevalence of multimorbidity, polypharmacy is inevitable. Sri Lanka too faces the burden of polypharmacy and multimorbidity, and it is a strain on the economy as Sri Lankan health care is free-of-charge to all citizens. Therefore, steps to reduce inappropriate polypharmacy are a necessity. The aim of the study was to assess the prevalence and patterns of polypharmacy and its associated factors. In the medical clinics of a tertiary care hospital and a University primary care department, a descriptive cross-sectional study was carried out. Data were extracted from the clinical records of patients over the age of 20 years with a minimum of one NCD diagnosed by either a consultant physician or a consultant family physician. The sample size was 1600. Multimorbidity was present among 63.5% of patients. Polypharmacy (five or more than five drugs) was seen in 36.8% of the patients. Diabetes, hypertension, and coronary heart disease were the commonest of all diseases. Those on more than 11 drugs were found to have diabetes mellitus, hypertension, coronary heart disease, chronic kidney disease, and cardiac failure. 15% of the patients in the primary care setting and 59% of the patients in tertiary care experienced polypharmacy. Multiple regression analysis confirmed that polypharmacy increased with male gender, advancing age, and the degree of multimorbidity. Horizontal and vertical integration of multidisciplinary teams in all disciplines to manage patients is needed to combat inappropriate polypharmacy. This will help in optimizing the management of patients with NCDs.

The 'work' of managing medications when someone is seriously ill and dying at home: A longitudinal qualitative case study of patient and family perspectives'

BACKGROUND

Managing medications can impose difficulties for patients and families which may intensify towards the end of life. Family caregivers are often assumed to be willing and able to support patients with medications, yet little is known about the challenges they experience or how they cope with these.

AIM

To explore patient and family caregivers' views of managing medications when someone is seriously ill and dying at home.

DESIGN

A qualitative design underpinned by a social constructionist perspective involving interviews with bereaved family caregivers, patients and current family caregivers. A thematic analysis was undertaken.

SETTING/PARTICIPANTS

Two English counties. Data reported in this paper were generated across two data sets using: (1) Interviews with bereaved family caregivers (n = 21) of patients who had been cared for at home during the last 6 months of life. (2) Interviews (n = 43) included within longitudinal family focused case studies (n = 20) with patients and current family caregivers followed-up over 4 months.

RESULTS

The 'work of managing medications' was identified as a central theme across the two data sets, with further subthemes of practical, physical, emotional and knowledge-based work. These are discussed by drawing together ideas of illness work, and how the management of medications can substantially add to the burden placed on patients and families.

CONCLUSIONS

It is essential to consider the limits of what it is reasonable to ask patients and families to do, especially when fatigued, distressed and under pressure. Focus should be on improving support via greater professional understanding of the work needed to manage medications at home.

The Association Between e-Health Literacy and Willingness to Deprescribe Among Patients with Chronic Diseases: A Cross-Sectional Study from Jordan

Background: Deprescribing refers to the partnered discontinuation of chronic medications to limit the negative impacts of polypharmacy. Polymedicated patients play a key role in the success of deprescribing efforts. eHealth literacy reflects patients' ability to appraise electronically available health-related information to make informed health care decisions, which partly reflect their desire to deprescribe. Objectives: The current study aimed to explore the relationship between eHealth literacy and willingness to deprescribe among patients with chronic diseases. Additionally, the predictors of willingness to deprescribe were examined. Materials and Methods: This cross-sectional study was conducted among adult patients with chronic diseases in Jordan. An online questionnaire comprising two validated tools, namely the Electronic Health Literacy Scale (eHEALS) and the Revised Patients' Attitudes Toward Deprescribing (rPATD) Questionnaire, was used for data collection. The questionnaire targeted adult patients with chronic medical conditions in Jordan and was posted to social media portals, following a convenience sampling technique. Results: A total of 719 responses were recorded and included in the final analysis. Participants with higher levels of eHealth literacy were more willing to get their medications deprescribed, as indicated by the perceived use of unneeded medications (p = 0.042). Meanwhile, participants with low levels of eHealth literacy were more likely to report fear of missing out on the potential benefits of deprescribed medications (p = 0.003). Other items that were commonly agreed upon by both the low and high eHealth literacy groups, respectively, included desire for dose reduction (p < 0.001, p < 0.001), belief in the lack of effectiveness of some prescribed medications (p < 0.001,p < 0.001), and fear of precipitating side effects (p = 0.001,p = 0.007). Conclusions: The present study highlighted the relationship between eHealth literacy and a number of items reflecting willingness to deprescribe, and these indicators can be used to guide future deprescribing efforts among eligible patients.

Potential Drug-Drug Interactions in Hospitalized Medical Patients: Data From Low Resource Settings

Introduction

Adverse events related to Drug-Drug Interactions (DDIs) are among the few common reasons for hospitalization worldwide; however, they can be prevented with an efficient patient-centered system. Different mechanisms have successfully limited the prevalence of DDIs in developed countries. There are limited data regarding DDIs from limited-resource settings. Furthermore, there is no cost-effective system that has shown promising results in preventing them in this setting. This study aims to assess the frequency of potential DDIs in a low-resource setting and to check its association with different factors such as poly-pharmacy and demographics.

Methods

Through this cross-sectional study, drug charts of patients admitted to a medical unit in November 2019 were analyzed using a structured questionnaire. A list of drugs co-prescribed to each patient was entered into the Medscape Drug Interaction checker to calculate the frequency and severity of potential DDIs.

Results

The mean age of patients was 49 years, and on average, seven drugs were prescribed to each patient. Among 100 analyzed prescriptions, 400 potential DDIs were identified with a mean of 4±5.42 per patient. According to Medscape interaction checker classification, 2 DDIs were contraindicated, 28 were serious, 246 required close monitoring, and 124 were minor. The most frequently encountered drug interaction was "spironolactone with furosemide." There was a significant correlation of the occurrence of potential DDIs with increased numbers of prescribed drugs.

Conclusion

Our patient population was prescribed more drugs per patient than calculated in other settings. Poly-pharmacy is an independent risk factor for DDIs. Lastly, advancing age exposes patients to poly-pharmacy, and therefore, they are at a higher risk of developing DDIs.

Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review

OBJECTIVE

To identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing.

SETTING

Primary care.

DATA SOURCES

Medline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021.

STUDY SELECTION

Included studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations.

DATA EXTRACTION

Screening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles.

RESULTS

Fifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added.

CONCLUSION

Activities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.

Deprescribing practice in a resource-limited setting: Healthcare providers' insights

AIMS

Inappropriate polypharmacy poses risks of adverse drug events, high healthcare costs and mortality. Deprescribing could minimise inappropriate polypharmacy and the consequences thereof. The aim of this study was to evaluate healthcare providers' (HCPs') attitudes toward and experiences with deprescribing practice in Ethiopia.

METHODS

We conducted an institution-based cross-sectional survey among HCPs at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. We used a validated questionnaire developed by Linsky et al. The tool included questions that explore medication characteristics, current patient clinical factors, predictions of future health states, patients' resources to manage their own health and education and experience. One-way ANOVA was used to test the association between sociodemographic variables and their perception of deprescribing decisions.

RESULTS

Of 85 HCPs approached, about 82 HCPs completed the survey, giving a response rate of 96.5%. Most of the participants (n = 73, 89%) have scored less than 1.5 points showing they are reluctant to proactively deprescribe. Physicians seem to be affected by the significant physical health conditions (mean = 1.68) and clinical endpoint like blood pressure (mean = 1.5) to make deprescribing decisions. According to the post hoc analysis of one-way ANOVA, clinical pharmacists seemed to have a better attitude toward deprescribing decisions compared with physicians (P = .025).

CONCLUSION

HCPs' decision to discontinue a medication could be multifactorial. Physicians could be influenced by physical health condition and clinical endpoints for deprescribing decision. Future studies should emphasise on barriers and facilitators to deprescribing practice specific to the context in Ethiopia.

Healthcare professionals' knowledge, attitudes and practices toward deprescribing: a protocol of cross-sectional study (Desmedica Study-Brazil)

BACKGROUND

Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit. It is an activity that should be a normal part of care/the prescribing cycle. Although now broadly recognised, there are still challenges in its effective implementation.

OBJECTIVES

To develop and validate an instrument to measure Brazilian healthcare professionals' knowledge, attitudes and practices towards deprescribing.

METHODS

This study will include the following steps: (1) development of the preliminary instrument; (2) content validation; (3) pilot study; (4) evaluation of psychometric characteristics. After the elaboration of items of the instrument through the literature review, we will use a hybrid Delphi method to develop and establish the content validity of the instrument. Further, a pilot survey will be performed with 30 healthcare professionals. Finally, for the evaluation of psychometric characteristics, a cross-sectional study will be accomplished with a representative sample of different healthcare professionals from different Brazilian states using respondent-driven sampling. Exploratory factor analysis and confirmatory factor analysis will be performed. For assessing the model fit, we will use the ratio of χ² and df (χ²/df), comparative fit index, the goodness of fit index and root mean square error of approximation. In addition, the reliability of the instrument will be estimated by test-retest reproducibility and Cronbach's alpha coefficient (α).

ETHICS AND DISSEMINATION

The Ethics Committee for Research at the University of Sorocaba (ethics approval number: 3.848.916) approved the study. Study findings will be circulated to healthcare professionals and scientists in the field through publication in peer-reviewed journals and conference presentations.

Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study

Background

More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.

Objective

To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.

Design

A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.

Setting

This took place in Nottinghamshire and Leicestershire, UK.

Results

As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.

Limitations

The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.

Conclusions

The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.

Future work

Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

Aspirin prescribing for cardiovascular disease in middle-aged and older adults in Ireland: Findings from The Irish Longitudinal Study on Ageing

Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.

Typology of drug discontinuation trials - Methodological recommendations

OBJECTIVE

Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation.

STUDY DESIGN AND SETTING

Multi-stage development process, including literature search and expert panels.

RESULTS

Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type.

CONCLUSION

We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.

Prescriber perspectives on low-value prescribing: A qualitative study

BACKGROUND

Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood.

OBJECTIVE

To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians.

DESIGN

Qualitative study using semi-structured interviews.

SETTING

Academic and community primary care practices within University of Pittsburgh Medical Center health system.

PARTICIPANTS

Sixteen primary care physicians.

MEASUREMENTS

We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing.

RESULTS

We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable.

CONCLUSIONS

Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Communicating deprescribing decisions made in hospital with general practitioners in the community

BACKGROUND

Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients.

AIMS

To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital.

METHODS

Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach.

RESULTS

GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long-term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow-up actions were crucial in a discharge summary to enable care post-discharge.

CONCLUSIONS

GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process.

The Prevalence of Selected Potential Drug-Drug Interactions of Analgesic Drugs and Possible Methods of Preventing Them: Lessons Learned From the Analysis of the Real-World National Database of 38 Million Citizens of Poland

Introduction: Drug-drug interactions may lead to poor health outcomes, as well as increased costs and utilization of healthcare services. Unfortunately, real-world data continuously prove high prevalence of potential drug-drug interactions (pDDIs) worldwide. Among identified drivers, ageing, multimorbidity and polypharmacy play a very important role. With these factors being widespread, the need for implementation of strategies minimizing the burden of pDDIs becomes an urgency. This, however, requires a better understanding of the prevalence of pDDIs and the underlying causative factors.

Aim of study: To assess the real-world prevalence of pDDIs and its characteristics in the general population of Poland, using analgesic drugs as a model, and to find out whether pDDIs are caused by prescribing coming from the very same prescribers (co-prescribing).

Methods: A retrospective analysis of the 2018 dispensation data of the National Health Fund (NHF) - the only Polish public healthcare payer organization with nationwide coverage. We searched for selected pDDIs of non-steroidal anti-inflammatory drugs (NSAIDs) with antihypertensives, other NSAIDs (double use), oral glucocorticoids, oral anticoagulants, selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and antiplatelet drugs; as well as opioides with SSRIs, SNRIs, gabapentinoids, and benzodiazepines. A pDDI was deemed present if two drugs standing in a possible conflict were dispensed within the same calendar month.

Results: Out of 38.4 million citizens of Poland, 23.3 million were dispensed prescribed drugs reimbursed by NHF in 2018. In this cohort, we have identified 2,485,787 cases of analgesic drug pDDIs, corresponding with 6.47% of the Polish population. Out of these, the most prevalent pDDI was caused by “NSAIDs + antihypertensives” (1,583,575 cases, i.e., 4.12% of the Polish population), followed by “NSAIDs + NSAIDs” (538,640, 1.40%) and “NSAIDs + glucocorticoids” (213,504, 0.56%). The most persistent pDDIs among those studied were caused by “Opioids + Gabapentinoids” (2.19, 95%CI: 2.16–2.22 months). On average, 76.63% of all cases of pDDIs were caused by drugs prescribed by the very same prescribers.

Conclusion: Based on high-quality, nationwide data, we have found a high prevalence of analgesic drugs-related pDDIs in Poland. Over ¾ of the identified pDDIs were caused by co-prescribing, i.e., prescriptions issued by the same prescribers. The significance of the problem, illustrated with our findings on analgesic drugs-related pDDIs in Poland, deserves much more scientific and policymaker attention.

Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences

RATIONALE, AIMS AND OBJECTIVES

Patients undergoing haemodialysis receive on average 10-17 medications, which increase the risk of falls, adverse drug reactions and hospitalizations. Supervised discontinuation of potentially inappropriate medications may lower these risks. Although many calls have been made for deprescribing in the haemodialysis setting, little is known about how patients and providers in this setting experience it. The aim of this study is to explore patient and provider experiences and perceptions of one of the rare deprescribing intervention in haemodialysis.

METHODS

Ten semi-structured interviews were held with patients, and a focus group was done with dialysis clinic team members at a Montreal area health network's haemodialysis clinic after the implementation of a standardized deprescribing intervention using the patient-as-partner approach. The interviews and focus group were recorded, and verbatims were coded to determine emerging themes. Grounded theory was used for interview guide design and data analysis.

RESULTS

The three emerging themes were (1) ambivalence towards medication creating a favourable context for deprescribing, (2) the empowering elements of the deprescribing process and (3) the uncertain future of deprescribing in the clinics even though the intervention was considered successful.

CONCLUSION

Haemodialysis patients and providers viewed deprescribing favourably, believed the intervention was valuable, and offered suggestions for long term implementation while expressing concerns about feasibility. Notwithstanding the underlying uncertainties, a structured and integrated approach in routine practice involving all members of the care team may facilitate the continuity of deprescribing as an intervention in the setting of a haemodialysis clinic.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Barriers and facilitators to deprescribing in primary care: a systematic review

BACKGROUND

Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.

AIM

To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.

DESIGN & SETTING

A systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.

METHOD

A search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.

RESULTS

In total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers' and patients' uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.

CONCLUSION

A whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Education around medication review and deprescribing: a survey of medical and pharmacy students' perspectives

Research into the practice of medication review is developing across the world in response to the ever-increasing burden of inappropriate polypharmacy. Education, training and support of undergraduates and novice practitioners to equip them to participate in the medication review process could lead to long-term shifts in practice. The purpose of this study was to explore the awareness of pharmacy and medical undergraduates about medication review, deprescribing and polypharmacy, in order to inform improvement strategies. In November 2016, all final-year medical and pharmacy students at a London (UK) university were invited to complete a short questionnaire survey. Qualitative analysis inductively themed free-text comments and quantitative analysis used descriptive statistics to summarize responses, with chi-square tests used to indicate differences between the groups. The overall response rate was 34% (171/500). The terms ‘medication review’ and ‘polypharmacy’ were known to the students, whilst the term ‘deprescribing’ was unfamiliar with no difference between the groups. The term ‘medication review’ meant different things to the groups: pharmacy students suggested a focus on adherence and patient understanding, whilst medical students focused on interactions and whether medicines were still indicated. The groups differed in their perceptions of who they thought undertook reviews, who identifies potentially inappropriate medicines, who makes the final decision to deprescribe and the frequency of medication reviews. Both groups reported that on qualification they would not be comfortable stopping a medicine without discussion with a senior colleague, but would be comfortable prompting a senior colleague to review. Both groups had some awareness of medication review tools. The meaning of the term ‘medication review’ differed between the student groups. While medical students focused on clinical aspects, pharmacy students emphasized patient experience. Both groups anticipated a lack of confidence in deprescribing without senior support, highlighting the need for alignment between education and professional development syllabi in a way that combines the variety of professional perspectives. Prompts by juniors could lead to more medication reviews within existing practice, and may give them invaluable experience in reviewing medicines in their future careers as seniors.

Barriers and enablers to collaborative working between GPs and pharmacists: a qualitative interview study

BACKGROUND

Many UK GP practices now employ a practice pharmacist, but little is known about how GPs and pharmacists work together to optimise medications for complex patients with multimorbidity.

AIM

To explore GP and pharmacist perspectives on collaborative working within the context of optimising medications for patients with multimorbidity.

DESIGN AND SETTING

A qualitative analysis of semi-structured interviews with GPs and pharmacists working in the West of England, Northern England, and Scotland.

METHOD

Thirteen GPs and 10 pharmacists were sampled from practices enrolled in the 3D trial (a complex intervention for people with multimorbidity). Participants' views on collaborative working were explored with interviews that were audiorecorded, transcribed, and analysed thematically. Saturation of data was achieved with no new insights arising from later interviews.

RESULTS

GPs from surgeries that employed a pharmacist tended to value their expertise more than GPs who had not worked with one. Three key themes were identified: resources and competing priorities; responsibility; and professional boundaries. GPs valued pharmacist recommendations that were perceived to improve patient safety, as opposed to those that were technical and unlikely to benefit the patient. Pharmacists who were not known to GPs felt undervalued and wanted feedback from the GPs about their recommendations, particularly those that were not actioned.

CONCLUSION

A good working relationship between the GP and pharmacist, where each profession understood the other's skills and expertise, was key. The importance of face-to-face meetings and feedback should be considered in future studies of interdisciplinary interventions, and by GP practices that employ pharmacists and other allied health professionals.

Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing

Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.