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

Geriatric education for pharmacy students: A scoping review

BACKGROUND

Comprehensive medication management for older adults requires specific knowledge and skills. Therefore, pharmacy curricula should include appropriate strategies to prepare students for care of this population. This scoping review aimed to identify how geriatric concepts, such as geriatric topics and competencies, are included in pharmacy curricula, and to map current literature on preferred teaching and assessment methods related to geriatric pharmacy education.

METHODS

Four databases were searched to identify papers involving pharmacy learners, education, and geriatrics. Selection process was a two-step approach, involving independent title/abstract screening by two reviewers, then full-text retrieval for eligibility assessment. All types of articles were considered except opinion papers. Data extraction included details on methodology, participants, setting, educational activity, teaching method, and outcomes assessed.

RESULTS

A total of 2537 articles were identified from which 189 met the inclusion criteria: 221 documents after citation and gray literature searching. Articles were grouped for analysis as education-related intervention articles (studies, n = 100 or descriptive articles/case reports, n = 49), studies not including an education-related intervention (n = 49), and others (e.g., reviews, position papers/statements, n = 23). Various teaching methods were reported including experiential, didactic, interprofessional, or simulation. Most articles reported positive outcomes on skills, knowledge, or attitudes, but few articles used a validated assessment tool. Curricula and student's surveys were consistent with suboptimal geriatric education, with few programs offering mandatory dedicated geriatric courses or rotations.

CONCLUSIONS

Gaps remain regarding geriatric inclusion in pharmacy curricula despite decades of evidence, advocacy, and frameworks to guide its development. A wide diversity of teaching methods has been described and their combination may be considered for skills and competency development. There is a need for the scholarship of teaching and learning to be applied to pharmacy programs in order to prepare future pharmacists for an aging society.

Prescribing deprescribing for polypharmacy in Aotearoa New Zealand; experiences of a medication review activity in final year medical students on a general practice module

Introduction This study explored the experiences of students and their supervisors undertaking a medication review activity during a 6-week general practice module in their final year of medical school at University of Otago, Wellington, Aotearoa New Zealand. Aim The study sought the self-reported value of the activity in learning about prescribing, reflecting on polypharmacy, deprescribing, and changes to future practice for both student and supervisor. Methods All students in the final year general practice module were invited to complete a survey over a 12-month period, as were their supervisors. An abductive thematic analysis of survey results was performed. Results Fifty-eight percent (48/87) of students and 30% (10/33) of supervisors completed surveys. Five themes were identified in the analysis of qualitative data: value of the medication review, complexities of medicines, importance of monitoring, value of resources, and supervisor reflections on value to the student. Student and supervisor responses reflected on prescribing practice beyond what medication to give when. All responses described benefit to patients and the majority expressed thoughts on how it would change their future prescribing. Discussion The medication review activity in the final year general practice module provides learning opportunities for both student and general practitioner supervisor. This activity emphasises the risks of polypharmacy and how to deprescribe. This study underlines the value of medication reviews as intraprofessional communication activities, allowing reflection beyond what medication to prescribe and for what condition. The results underline the importance of reflecting on practice and aids quality improvement benefit to patients.

Findings from an expert focus group on psychotropic medication deprescribing practices for children and youth with complex needs

Introduction

Psychotropic medication can be effective at stabilizing emotional and behavioural disturbances associated with physiological processes in children and youth. When medication benefits, indication or adverse effects are queried, deprescribing should be considered. Current guidelines for deprescribing are mainly for adults/elderly and largely theoretical, not practical, especially for polypharmacy.

Methods

At a tertiary center for children and youth with complex emotional and behavioural needs, physicians on staff have expertise in conducting assessments of medication efficacy, side effect burden, and safety concerns. Deprescribing is routinely undertaken in the context of inpatient and outpatient services in partnership with children/youth and their families. A qualitative initiative leveraged the specialized deprescribing expertise of eight physicians (six psychiatrists and two pediatricians).

Results

Emerging themes were medication review, timing, a stepwise approach, and setting conditions (inpatient and outpatient), with recurring subcategories of patient/family engagement as well as the underlying importance of continuity of care with psychosocial/behavioural supports.

Discussion

The findings from this expert focus group serve as a step towards supporting prescribing clinicians in mindful deprescribing when medications are no longer in the best interest of young patients.

"I think deprescribing is very needed in our society:" Healthcare Professional Students Perceptions of Deprescribing Education

Introduction: Deprescribing is a complex and pivotal process in the healthcare system that requires the involvement of different healthcare professionals, as well as patients and family members. Given the multifaceted healthcare professionals involved in deprescribing, fostering interdisciplinary healthcare teams during the didactic and experiential educational engagement is imperative. Thus, this study aimed to characterize healthcare professional students' opinions on the importance of an interdisciplinary approach to deprescribing during the didactic and experiential components of the curriculum. Methods: This qualitative study was conducted with healthcare professional students enrolled in a professional degree program at one Mid-South health science center located in the US. Focus groups were conducted via an online platform over three months in 2022, and recruitment continued until thematic saturation was achieved. Using Thematic Analysis, the corpus of the transcribed data was imported into Dedoose®, a qualitative software that facilitated the analysis. Results: A total of 36 healthcare professional students participated in four focus groups. Three themes emerged from the data: 1) setting the stage for deprescribing, 2) developing interprofessional deprescribing simulations, 3) potential positive patient outcomes. In the first theme, the healthcare professional students describe current challenges in the deprescribing process that call attention to the interprofessional nature of deprescribing. The second theme demonstrates the necessity of developing interprofessional simulations to educate healthcare professional students in the practice of deprescribing. Finally, in the third theme, the healthcare professional students illustrate the potential of interprofessional education on deprescribing to improve patient outcomes. Conclusion: The data highlights that there was strong agreement between extant literature and health professions participants on barriers to deprescribing, including interprofessional communication issues, and on the recommendation to enact interprofessional healthcare simulation education on deprescribing. In addition, the potential benefits of increased interprofessional education will provide immeasurable benefits and create an ample understanding of the health professions roles. These findings suggest that deprescribing focused interprofessional healthcare simulation educational activities should be conducted and assessed.

Current Landscape and Future Directions of Deprescribing and Polypharmacy Practices in Jordan

This review explores the current landscape and future directions of deprescribing and polypharmacy practices in Jordan. The prevalence of polypharmacy, defined as the concurrent use of multiple medications by an individual, has been increasing in recent years due to various factors, such as population aging and the greater availability of medications. However, polypharmacy can lead to adverse drug events, suboptimal medication adherence, increased healthcare costs, and reduced quality of life. Deprescribing, on the other hand, involves the discontinuation or reduction of unnecessary or potentially harmful medications to improve patient outcomes. The findings presented in this review highlight the current state of deprescribing and polypharmacy practices in Jordan, including factors influencing their prevalence. Additionally, it discusses the challenges healthcare professionals face in implementing deprescribing strategies and identifies potential solutions for enhancing these practices in Jordanian healthcare settings. Moreover, this paper provides insights into future directions for deprescribing and polypharmacy practices in Jordan. Overall, this review offers valuable insights into the current landscape of deprescribing and polypharmacy practices in Jordan while also providing recommendations for future directions to optimize medication management strategies that can ultimately benefit patient outcomes within a sound healthcare system framework.

Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives

BACKGROUND

Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects.

METHODS

We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences.

RESULTS

The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

CONCLUSION

The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

Student Perspectives on the Pharmacist's Role in Deprescribing Opioids: A Qualitative Study

INTRODUCTION

Opioid over-prescribing has led to changes in prescribing habits and a reduction in the amount of opioid prescriptions per patient. Deprescribing has proved to be an effective way of decreasing the number of opioids patients are receiving, and pharmacists are in the optimal position to provide these services for their patients. However, student pharmacists require additional education and training to be able to understand their role in deprescribing opioids upon entering the profession.

METHODS

Student pharmacists at three United States of America schools of pharmacy were invited to participate in virtual focus groups about deprescribing opioids in Fall 2021. A trained qualitative researcher conducted the focus groups, which were audio-recorded and later transcribed verbatim for thematic analysis. Two independent qualitative researchers coded the transcripts using both inductive and deductive approaches. The researchers then met to identify, discuss, and describe themes from the data.

RESULTS

Thematic analysis revealed two themes: (1) perceived obstacles and enablers to initiate deprescribing for opioid medications and (2) additional pharmacy curricula experiences are necessary to better equip student pharmacists to address deprescribing. These themes emphasize the challenges student pharmacists face as well as opportunities to enhance their knowledge to be practice-ready.

CONCLUSION

Varying educational approaches to teaching deprescribing in the pharmacy curriculum, including objective structured clinical exams, interprofessional education, and motivational interviewing, should be further assessed.

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.

A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing

Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01704-9.

Teaching Deprescribing and Combating Polypharmacy in the Pharmacy Curriculum: Educational Recommendations from Thematic Analysis of Focus Groups

In the last two decades in the United States (US), the previous research has focused on medication optimization, including polypharmacy. Polypharmacy is associated with several negative outcomes, which may be resolved by deprescribing medications that are no longer necessary. Although deprescribing is a critical aspect of a pharmacist's role, some studies have demonstrated that student pharmacists are less familiar with their future role in deprescribing. Thus, this study aimed to explore student pharmacists' perceptions of deprescribing in the pharmacy curriculum. This qualitative study was conducted with student pharmacists enrolled in three Doctor of Pharmacy (Pharm.D.) programs in the US. The participants, all student pharmacists at the time of the study, were identified via an email requesting their voluntary participation in a focus group study. The focus groups were conducted via an online platform over three months in 2022, and recruitment continued until thematic saturation was obtained. Using thematic analysis, the corpus of the transcribed data was imported into Dedoose^®, a qualitative software that facilitated the analysis. Three themes emerged from the data: (1) the importance of deprescribing; (2) barriers to deprescribing; (3) education recommendations. The data highlight that the student pharmacists believe integrating deprescribing content into the clinical, didactic, and simulation education would help them overcome the identified obstacles. Colleges of pharmacy should consider emphasizing the importance of deprescribing in their curriculum, creating programs to assist future pharmacists in addressing the barriers to deprescribing, and adopting the suggested educational strategies to improve the deprescribing education that is offered.

Differences in Factors Influencing Deprescribing between Primary Care Providers: Cross-Sectional Study

Deprescribing is a notable approach to improve medication management, but few healthcare systems recognize it. To introduce a new practice, it is important to examine the factors influencing the provision of a new or elaborate cognitive service within the desired setting. This study explores the perceived barriers and facilitators of deprescribing by primary healthcare providers, and identifies the factors associated with a willingness to suggest deprescribing. A cross-sectional survey was conducted (in Croatia, between October 2021 and January 2022) using a validated comprehensive healthcare providers' opinions, preferences, and attitudes towards deprescribing (CHOPPED) questionnaire. A total of 419 pharmacists and 124 physicians participated. Participants showed a high willingness to deprescribe, with significantly higher scores in physicians than in pharmacists (5.00 (interquartile range-IQR 5-5) vs. 4.00 (IQR 4-5), p < 0.001). Pharmacists had significantly higher scores in seven out of ten factors (knowledge, awareness, collaboration facilitators, competencies facilitators, healthcare system facilitators, collaboration barriers, competencies barriers) while in the remaining three factors (patient facilitators, patient and healthcare system barriers) there was no difference in scores. The strongest positive correlation with willingness to suggest deprescribing was found with the collaboration and healthcare system facilitators factors for pharmacists (G = 0.331, p < 0.001, and G = 0.309, p < 0.001, respectively), and with knowledge, awareness, and patient facilitators factors for physicians (G = 0.446, p = 0.001; G = 0.771, p < 0.001; and G = 0.259, p = 0.043, respectively). Primary healthcare providers are willing to suggest deprescribing but face different barriers and facilitators. For pharmacists, the most important facilitators were extrinsic, while for physicians they were more intrinsic and patient related. The stated results provide target areas which one could focus upon to help to engage healthcare providers in deprescribing.

Supporting Interprofessional Collaboration in Deprescribing: Needs Assessment for an Education Program

INTRODUCTION

: Deprescribing is a complex process involving patients and healthcare providers. The aim of the project was to examine the learning needs and preferences of healthcare providers and students to inform the development of an interprofessional deprescribing education program.

METHODS

: An online survey of pharmacists, nurses, nurse practitioners, family physicians, and associated students practicing or studying in Nova Scotia was conducted. Respondents were recruited by purposive and snowball sampling to have at least five respondents within each professional/student group. Questions captured participant's self-reported comfort level and professional role for 12 deprescribing tasks and their learning preferences.

RESULTS

: Sixty-nine respondents (46 healthcare providers and 23 students) completed the questionnaire. Average comfort levels for all 12 deprescribing tasks ranged from 40.22 to 78.90 of 100. Respondents reported their preferred deprescribing learning activities as watching videos and working through case studies. Healthcare providers preferred to learn asynchronously online, while students preferred a mix of online and in-person delivery.

DISCUSSION

: Learning needs related to deprescribing tasks and roles were identified, as well as preferences for format and delivery of education. Development of an education program that can provide a shared understanding of collaborative deprescribing tailored to learner preferences may improve deprescribing in practice.

“I Think Deprescribing as a Whole Is a Gap!”: A Qualitative Study of Student Pharmacist Perceptions about Deprescribing

Introduction: Older adults often manage multiple medications simultaneously, contributing to significant pill burden. Pill burden is a major concern for both patients and providers alike, and student pharmacists may play a role in decreasing that burden. Few studies exist evaluating student pharmacists’ roles in and perceptions of deprescribing in the healthcare team. Thus, the aim of this study was to explore student pharmacist perceptions regarding deprescribing in their pharmacy curricula. Methods: This study used a focus group discussion (FGD) methodology to facilitate discussion on deprescribing among student pharmacists. The theory of planned behavior (TPB) informed the conceptualization of this study, data collection, and thematic analysis. Student pharmacists enrolled in three different colleges of pharmacy across various geographical regions of the U.S. were recruited to participate in the study. Data collection occurred in the Fall of 2021, and recruitment proceeded until thematic saturation was achieved. The audio recordings were transcribed verbatim, and the transcripts were uploaded into Dedoose®, a qualitative software that facilitated the data analysis. The inductive codes were grouped into categories based on similarities that resulted in the themes. Results: Three colleges, totaling 1366 student pharmacists across different geographic regions of the U.S., were invited to participate in this study (UTHSC, N = 682; UNE, N = 158, University of Arizona, N = 526). Twenty-six student pharmacists participated in four FGDs. Of 26 participants, fourteen self-identified as male and two declined to state their gender identity. The mean age was 24 years old, with participants ranging from 21 to 37 years old. Thematic analysis revealed two major themes: (1) student pharmacists indicated that they possessed limited information about the deprescribing process, which is best illustrated by the following quote: “I think deprescribing as a whole is a gap!”; and (2) student pharmacists recommended increasing emphasis on deprescribing in pharmacy curricula. Conclusions: Student pharmacists identified few educational experiences on deprescribing in their curriculum while demonstrating a strong desire for more emphasis on deprescribing in the pharmacy curricula. This study highlights an opportunity to improve the integration of deprescribing education into pharmacy curricula, and colleges of pharmacy should evaluate whether, where, and to what extent the incorporation of this topic into their curricula is appropriate.

Impediments to deprescription in Brazil: overview from a panel of geriatrics experts

Objectives: To identify impediments to deprescription among older adults from the perspective of a panel of Brazilian geriatricians. Methods: The Delphi method was used to obtain a consensus among Brazilian geriatricians about the factors that influence the lack of deprescription for older adults in clinical practice. The study was developed in two stages: (i) a survey and description of potential factors involved in deprescription; and (ii) applying the results of the survey to a panel of experts to obtain a consensus. Results: The deprescription process is influenced by the interaction of three pillars of older adult health care: the prescriber, the patient-family, and the health care system. In the professional and health care systems, professional training and communication skills, prolonged clinical follow-up, access to the multidisciplinary team, medical consultations of an adequate time, and unified electronic health records were identified as facilitators of deprescription. In the patient-family pillar, clear facilitators included health literacy, no sensory or cognitive deficits, and a clinical situation of transitional or palliative care. Conclusions: Deprescription is a complex, multifactorial process that requires attention, time, and specific skills and competencies from the attending physician, but it also requires shared decision-making and a health system compatible with a culture of deprescription.

Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs

BACKGROUND

Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives.

OBJECTIVES

To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives.

METHODS

Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW.

RESULTS

Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications.

CONCLUSIONS

This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.

Deprescribing perceptions and practice: Reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module

BACKGROUND

There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing.

OBJECTIVES

1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students.

METHODS

A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module.

RESULTS

Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions.

CONCLUSIONS

Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.