Older adults' adherence to medications and willingness to deprescribe: A substudy of a randomized clinical trial

Our study investigated the association between patients' willingness to have medications deprescribed and medication adherence. This longitudinal substudy of the 'Optimizing PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial, a cluster randomized controlled trial, took place in Swiss primary care settings. Participants were aged ≥65 years and over, with ≥3 chronic conditions and ≥5 regular medications. At baseline, the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire was measured. The A14-scale measured adherence (self-report) at the 12-month follow-up. Multilevel linear regression analyses adjusted for baseline variables were performed. Of the 298 participants, 45% were women, and the median age was 78. Participants reported a high level of adherence and willingness to have medications deprescribed. We did not find evidence for an association between patients' willingness to deprescribe and medication adherence. Further research is needed to explore the relationship between these concepts and to inform collaborative decisions about medicines in the context of polypharmacy.

Evolving Trends and Economic Burden of Benzodiazepine Use: Insights From a 10-Year Predictive Model

OBJECTIVES

Benzodiazepines (BZDs) are widely prescribed in Croatia to treat anxiety, insomnia, mood disorders, and epileptic seizures. Long-term BZD use is associated with memory loss, Alzheimer's disease, dependence, addiction, falls in elderly populations, and increased traffic accident risk.

METHODS

Drug consumption data were obtained from the Agency for Medicinal Products and Medical Devices of Croatia website. Autoregressive integrated moving average models, constructed using R programming language, forecasted diazepam, alprazolam, and overall BZD utilization and financial costs at a national level over 10 years.

RESULTS

BZD consumption increased by up to 18.6% between 2012 and 2020. During the same period, diazepam utilization rose by 29.1%, and alprazolam consumption increased by 19.4%. Our model predicts that, by 2032, BZD, diazepam, and alprazolam utilization will increase substantially. The total projected financial expenditure for BZDs in 2032 is estimated at 14.22 million euros, with diazepam and alprazolam expenditures at 7.39 and 4.12 million euros, respectively. These increases will result in significant growth in healthcare spending and a rise in adverse effects related to long-term use.

CONCLUSIONS

National healthcare decision makers should consider implementing regulatory and legislative measures to quantify, specify, and limit monthly BZD use for each patient. This would help control the negative side effects of prolonged BZD use while continuing to provide treatment for patients who genuinely need it.

Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis

OBJECTIVES

The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia.

DESIGN

A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group.

SETTING AND PARTICIPANTS

Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019.

METHODS

Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars.

RESULTS

The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period.

CONCLUSIONS AND IMPLICATIONS

Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

Clinical decision-making in benzodiazepine deprescribing by healthcare providers vs. AI-assisted approach

AIMS

The aim of this study was to compare the clinical decision-making for benzodiazepine deprescribing between a healthcare provider (HCP) and an artificial intelligence (AI) chatbot GPT4 (ChatGPT-4).

METHODS

We analysed real-world data from a Croatian cohort of community-dwelling benzodiazepine patients (n = 154) within the EuroAgeism H2020 ESR 7 project. HCPs evaluated the data using pre-established deprescribing criteria to assess benzodiazepine discontinuation potential. The research team devised and tested AI prompts to ensure consistency with HCP judgements. An independent researcher employed ChatGPT-4 with predetermined prompts to simulate clinical decisions for each patient case. Data derived from human-HCP and ChatGPT-4 decisions were compared for agreement rates and Cohen's kappa.

RESULTS

Both HPC and ChatGPT identified patients for benzodiazepine deprescribing (96.1% and 89.6%, respectively), showing an agreement rate of 95% (κ = .200, P = .012). Agreement on four deprescribing criteria ranged from 74.7% to 91.3% (lack of indication κ = .352, P < .001; prolonged use κ = .088, P = .280; safety concerns κ = .123, P = .006; incorrect dosage κ = .264, P = .001). Important limitations of GPT-4 responses were identified, including 22.1% ambiguous outputs, generic answers and inaccuracies, posing inappropriate decision-making risks.

CONCLUSIONS

While AI-HCP agreement is substantial, sole AI reliance poses a risk for unsuitable clinical decision-making. This study's findings reveal both strengths and areas for enhancement of ChatGPT-4 in the deprescribing recommendations within a real-world sample. Our study underscores the need for additional research on chatbot functionality in patient therapy decision-making, further fostering the advancement of AI for optimal performance.

Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study

OBJECTIVE

To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes.

DESIGN

Multicenter retrospective cohort study.

SETTING AND PARTICIPANTS

Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018.

METHODS

Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis.

RESULTS

Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB.

CONCLUSIONS AND IMPLICATIONS

CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.

A Tool for Deprescribing Antithrombotic Medication in Palliative Cancer Patients: A Retrospective Evaluation

Treating palliative cancer patients with antithrombotics is challenging because of the higher risk for both venous thromboembolism and major bleeding. There is a lack of available guidelines on deprescribing potentially inappropriate antithrombotics. We have therefore created an antithrombotics scheme to aid in (de)prescribing antithrombotics. A retrospective single-center clinical cohort observational study was performed to evaluate it. Patients with solid tumors with a life expectancy of less than 3 months seen by the palliative team were included. Comparisons were made between patients who were treated according to the antithrombotics scheme and those who were not. 47.6% of patients used antithrombotics. One hundred and eleven patients were included for analysis. Most patients used antithrombotics according to the scheme (n = 80, 72.1%). Eleven patients experienced a clinical event, seven patients in the scheme adherence group (9.9%) and four in the no scheme adherence group (13.8%), which was not statistically significant (p = 0.726). The higher frequency of clinical events in the group without scheme adherence suggests that (de)prescribing antithrombotics according to the antithrombotics scheme is safe. The results of this study suggest that the antithrombotics scheme could aid healthcare professionals identifying possible inappropriate antithrombotics in palliative cancer patients. Further prospective research is needed to investigate this tool.

Deprescribing psychotropic medications is associated with improvements in activities of daily living in post-stroke patients

AIMS

To examine the effect of deprescribing psychotropic medications on activities of daily living (ADLs) and swallowing function in patients undergoing convalescent rehabilitation following a stroke.

METHODS

In this retrospective cohort study, patients who underwent convalescent rehabilitation after a stroke were divided into two groups: deprescribing (number of psychotropic medications decreased during hospitalization) and non-deprescribing (number of psychotropic medications increased or remained unchanged). The primary outcome measure was ADLs assessed using the Functional Independence-Measured Motor Activity (FIM-motor) score at discharge. A multiple linear regression analysis was conducted to determine the independent association between deprescribing psychotropic medications and rehabilitation outcomes.

RESULTS

Of the 586 patients enrolled, 128 with a mean age of 74.1 ± 12.7 years were included in the final analysis after being prescribed psychotropic medications, with 36 of them (28.1%) in the deprescribing group. Multiple linear regression analysis revealed that deprescribing psychotropic medications was independently associated with FIM-motor function at discharge.

CONCLUSIONS

Deprescribing psychotropic medications is positively associated with improvements in ADLs among patients undergoing convalescent rehabilitation after a stroke. Geriatr Gerontol Int 2024; 24: 275-282.

Deprescribing in Older Poly-Treated Patients Affected with Dementia

Polypharmacy is an important issue in older patients affected by dementia because they are very vulnerable to the side effects of drugs'. Between October 2021 and September 2022, we randomly assessed 205 old-aged outpatients. The study was carried out in a Center for Dementia in collaboration with a university center. The primary outcomes were: (1) deprescribing inappropriate drugs through the Beers and STOPP&START criteria; (2) assessing duplicate drugs and the risk of iatrogenic damage due to drug-drug and drug-disease interactions. Overall, 69 men and 136 women (mean age 82.7 ± 7.4 years) were assessed. Of these, 91 patients were home care patients and 114 were outpatient. The average number of the drugs used in the sample was 9.4 drugs per patient; after the first visit and the consequent deprescribing process, the average dropped to 8.7 drugs per patient (p = 0.04). Overall, 74 potentially inappropriate drugs were used (36.1%). Of these, long half-life benzodiazepines (8.8%), non-steroidal anti-inflammatory drugs (3.4%), tricyclic antidepressants (3.4%), first-generation antihistamines (1.4%), anticholinergics (11.7%), antiplatelet drugs (i.e., ticlopidine) (1.4%), prokinetics in chronic use (1.4%), digoxin (>0.125 mg/day) (1.4%), antiarrhythmics (i.e., amiodarone) (0.97%), and α-blockers (1.9%) were included. The so-called "duplicate" drugs were overall 26 (12.7%). In total, ten potentially dangerous prescriptions were found for possible interactions (4.8%). We underline the importance of checking all the drugs taken periodically and discontinuing drugs with the lowest benefit-to-harm ratio and the lowest probability of adverse reactions due to withdrawal. Computer tools and adequately trained teams (doctors, nurses, and pharmacists) could identify, treat, and prevent possible drug interactions.

Deprescribing electronic case reviews for older veterans at risk for falls: Effects on drug burden and falls

BACKGROUND

Falls are the most common medication-related safety event in older adults. Deprescribing fall risk-increasing drugs (FRIDs) may mitigate fall risk. This study assesses the effects of an innovative deprescribing program in reducing FRID burden and falls-related acute visits over 1 year.

METHODS

The Falls Assessment of Medications in the Elderly (FAME) Program is a pilot deprescribing program designed to improve medication safety in Veterans aged ≥65, screening positive for high fall risk at the Durham Veterans Affairs Health Care System. Central case finding and electronic case reviews with deprescribing recommendations were completed by an interdisciplinary team, forwarded to prescribers for approval, then implemented during follow-up telephone visits by FAME team. Primary outcome was change in FRID burden calculated by modified Drug Burden Index (DBI) at 1 year and an exploratory outcome was 1-year fall-related acute visits.

RESULTS

Overall, 472 patients (236 intervention cases, 236 matched controls) were included in the study. Of the 236 patients receiving a FAME deprescribing plan, 147 had recommendations approved by prescriber and patient. In the intention-to-treat analysis, the 1-year change in modified DBI was -0.15 (95% CI -0.23, -0.08) in the intervention cohort and -0.11 (-0.21, -0.00) in the matched control cohort (p = 0.47). The odds of increasing DBI by a clinically important threshold of 0.5 was significantly lower in the FAME cohort (OR 0.37, 0.21, 0.66). Fall-related acute events occurred in 6.3% of patients in the intervention group versus 11.0% in control patients over a one-year period (p = 0.10).

CONCLUSIONS

The program was associated with a significantly lower odds of further increasing FRID burden at 1 year compared to matched controls. An electronic case review and telephone counseling program has the potential to reduce drug-related falls in high-risk older adults.

Polypharmacy and Deprescribing in Older Adults

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

Influence of Potentially Inappropriate Medication Use on Older Australians' Admission to Emergency Department Short Stay

Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90-12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11-1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.

Prescribing and deprescribing in older people with life-limiting illnesses receiving hospice care at the end of life: A longitudinal, retrospective cohort study

BACKGROUND

Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population.

AIMS

To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use.

DESIGN

A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al.

SETTING/PARTICIPANTS

Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded.

RESULTS

Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed.

CONCLUSIONS

In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death.

Inappropriate polypharmacy management versus deprescribing: A review on their relationship

Medication burden and polypharmacy are highly prevalent among patients with multimorbidity. There have been multiple initiatives to overcome polypharmacy and medication burden in patients with multimorbidity. These initiatives have evolved over time as effective in reducing the negative health consequences of polypharmacy. In recent years, the concept and practice of deprescribing has emerged and gained popularity as an efficient comprehensive approach to manage polypharmacy and ultimately improve health outcomes. Clinicians and researchers with interest in deprescribing view it as a novel and unique strategy that should be a part of effective prescribing process. However, other traditional polypharmacy management strategies such as drug review and medication therapy management still coexist. It is intriguing if deprescribing is considered as a type of these strategies or not. This narrative mini-review explored published literature in an effort to ascertain the differences and similarities between deprescribing and other prominent polypharmacy management interventions. It is clear that there is an overlap between deprescribing and inappropriate polypharmacy management. This is represented by focusing on multimorbid older adults, using similar explicit and implicit tools and having drug review as the core principle of both approaches. This overlap has probably made deprescribing considered as one of polypharmacy management approaches.

Attitudes towards deprescribing in geriatric psychiatry: A survey among older psychiatric outpatients

Understanding the patient perspective is a significant part of the deprescribing process. This study aimed to explore the attitudes of older patients with psychiatric disorders towards deprescribing. A total of 72 of psychiatric outpatients (68% women; median age 76 years) completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Patients used a median of eight medications (interquartile range 6-12), with 88%, 49% and 24% using antidepressants, antipsychotics and anxiolytics, respectively. Fifty-one percent of patients reported an intrinsic desire to stop one of their medications, while 92% would be willing to stop one on their physician's advice. Seventy-five percent of patients would be worried about missing out on future benefits following deprescribing and 37% had previous bad deprescribing experiences. Use of ≥8 regular medications was associated with more concerns about stopping medication and greater perceived burden of using medication, while use of antipsychotics was not associated with any differences in rPATD factor scores. It is crucial for health care professionals to be aware of patients' specific concerns and past experiences to promote a patient-centred deprescribing approach that takes into account the needs and preferences of older patients with psychiatric disorders.

How does deprescribing (not) reduce mortality? A review of a meta-analysis in community-dwelling older adults casts uncertainty over claimed benefits

Some meta-analyses suggest that deprescribing may reduce mortality. Our aim was to determine the underlying factors contributing to this observed reduction. We analysed data from 12 randomized controlled trials included in the latest meta-analysis on deprescribing in community-dwelling older adults. Our analysis focused on deprescribed medications and potential methodological concerns. Only a third (4/12) of the trials aimed to study mortality, and that too as a secondary outcome. Five trials reported a reduction in total medications, potentially inappropriate medications or drug-related problems. Information on specific classes of deprescribed medications was limited, although a wide array was concerned (e.g., antihypertensive, sedative, gastro-intestinal medications and vitamins). Follow-up periods were ≤1 year in 11 trials, and five trials included ≤150 participants. Small sample sizes often resulted in imbalanced groups (e.g., comorbidities, number of potentially inappropriate medications), yet no trials presented multivariable analyses. In the two trials with the most weight in the meta-analysis, several deaths occurred before the intervention, making it difficult to draw conclusions about the impact of the deprescribing intervention on mortality. These methodological issues cast significant uncertainty on the benefits of deprescribing on mortality outcomes. Large-scale, well-designed trials are needed to address this issue effectively.

Deprescribing Tool for Older PeoPle with Limited-life Expectancy (De-TOPPLE) version 1: Development and validation using a modified Delphi technique

Deprescribing decision making in older adults with limited life expectancy is often challenging for clinicians. We aimed to develop and validate a Deprescribing Tool for Older People with Limited-life Expectancy (De-TOPPLE). Modified Delphi technique was used to gain experts' consensus on the tool and further develop using their feedback. Experts [Round-1 (n = 13), Round-2 (n = 7)] had clinical and/or research background on geriatric medicine, geriatrics, family medicine or pharmacotherapy. Round-1 consensus was achieved on approach taken by the tool to evaluate risk and benefit; distinguishing medications as preventive, symptom control or dual-purpose; referring to established deprescribing process; stepwise approach to deprescribing; and the overall concept. Common feedback was to reflect upon harm-benefit analysis, distinguish medication types earlier, qualify adverse events, use time-to-benefit (TTB), prioritise symptom relief, monitor post-deprescribing, include shared decision making and define terms for clinical familiarisation. After tool update, Round-2 consensus was achieved on usability in clinical setting, flexibility of implicit judgement, ceasing preventive medication with inadequate TTB, ceasing symptom control medication with inadequate symptom relief, ceasing dual-purpose medication (DPM) with inadequate TTB and symptom relief, and continuing DPM with adequate TTB and symptom relief. De-TOPPLE version 1 was developed and validated through two rounds of the Delphi process. Clinical use of the tool needs final validation following the addition of contextual statements to the tool.

Exploration of the barriers and enablers of benzodiazepines deprescribing in prisons: A qualitative study among health and social care professionals

BACKGROUND

The prison environment is a place of high consumption of benzodiazepines (BZDs) due to the anxiety and sleep disturbances, mental disorders, detoxification and trafficking.

OBJECTIVE

The study aims to explore experiences of health and social care professionals on the use of BZDs in prisons, as well as the barriers and enablers to their deprescribing.

METHOD

Semistructured individual interviews with professionals working in a prison setting were performed between March and April 2022, based on an interview guide. They were recorded and transcribed using the NVivo software. A qualitative analysis using an inductive approach based on a thematic analysis was performed.

RESULTS

Sixteen health professionals were interviewed, including psychiatrists, general practitioners, nurses, pharmacists, psychologists, musicologists and pharmacy technicians. The identified barriers to deprescribing BZDs were problems of coordination between prescribers, lack of time and alternatives. Concerning the enablers, therapeutic education groups, staff's awareness of the irrelevance of some medication and multi-professional advice were identified.

DISCUSSION

This study highlights the similarities in deprescribing difficulties between prison and other settings. Some of the levers identified in our study have shown their effectiveness in different settings.

CONCLUSION

Deprescribing is done most of the time in good conditions but requires an additional delay compared to the outside environment.

Deprescribing in primary care without deterioration of health-related outcomes: A real-life, quality improvement project

Medication reviews focusing on deprescribing can reduce potentially inappropriate medication; however, evidence regarding effects on health-related outcomes is sparse. In a real-life quality improvement project using a newly developed chronic care model, we investigated how a general practitioner-led medication review intervention focusing on deprescribing affected health-related outcomes. We performed a before-after intervention study including care home residents and community-dwelling patients affiliated with a large Danish general practice. The primary outcomes were changes in self-reported health status, general condition and functional level from baseline to 3-4 months follow-up. Of the 105 included patients, 87 completed the follow-up. From baseline to follow-up, 255 medication changes were made, of which 83% were deprescribing. Mean self-reported health status increased (0.55 [95% CI: 0.22 to 0.87]); the proportion with general condition rated as 'average or above' was stable (0.06 [95% CI: -0.02 to 0.14]); and the proportion with functional level 'without any disability' was stable (-0.05 [95% CI: -0.09 to 0.001]). In conclusion, this general practitioner-led medication review intervention was associated with deprescribing and increased self-reported health status without the deterioration of general condition or functional level in real-life primary care patients. The results should be interpreted carefully given the small sample size and lack of control group.

Survey content validation evaluating the dissemination and implementation of deprescribing guidelines

BACKGROUND

Policies, protocols and processes within organisations can facilitate or hinder guideline adoption. There is limited knowledge on the strategies used by organisations to disseminate and implement evidence-based deprescribing guidelines or their impact.

METHODS

We aimed to develop an online survey targeting key organisations involved in deprescribing guideline endorsement, dissemination, modification or translation internationally. Survey questions were drafted, mirroring the six components of the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Content validation was undertaken and established by a panel of clinicians, researchers and implementation experts.

RESULTS

A 52-item survey underwent two rounds of content validation. The minimum threshold (I-CVI > 0.78) for relevance and importance was met for 39 items (75%) in the first round and 44 of 48 items (92%) in the second round. The expert panel concluded that the adoption, implementation and effectiveness survey sections were largely relevant and important to this topic, whereas the reach and maintenance sections were harder to understand and may be less pertinent to the research question.

CONCLUSIONS

A 44-item survey investigating dissemination and implementation strategies for deprescribing guidelines has been developed and its content validated. Widespread survey distribution may identify effective strategies and inform dissemination and implementation planning for newly developed guidelines.

Use of deprescribing search filters in systematic review search strategies: A case study

Two deprescribing search filters for MEDLINE and one deprescribing search filter for Embase have been recently developed, including objectively developed search filters. The objective of this case study was to implement these three deprescribing search filters in systematic review (SR) search strategies and to assess their effect on performances. SR that independently developed original search strategies (OSS) were selected. The deprescribing filters were implemented in each OSS, generating two implemented search strategies (ISS1 and ISS2) in MEDLINE and one ISS (ISS3) in Embase. OSS were re-run on the same date as ISS. The performances of ISS and OSS were calculated and compared. Two SR were included (SR1 and SR2). For MEDLINE, SR1 included 12 articles. The sensitivity was 50% for OSS, 58% for ISS1 and 42% for ISS2. SR2 included four articles. The sensitivity of OSS, ISS 1 and 2 was 25%. For Embase, SR1 included 12 articles. The sensitivity was 33% for OSS and 58% for ISS3. SR2 included four articles. None of the four included articles were retrieved with OSS or ISS3. While sensitivity of OSS was moderate, the objectively developed deprescribing filters maintained or slightly improved this sensitivity when implementing.

Older Adult Attitudes toward Deprescribing Statins in Primary Cardiovascular Prevention Versus General Medications

Background: There is little evidence for statins for primary cardiovascular prevention in older adults. Consequently, it is important to assess patient attitudes toward the use of statins, which might differ from attitudes toward other medications. We aimed to describe older patient attitudes toward deprescribing statins versus general medications. Methods: We conducted a survey using the revised Patients' Attitudes Toward Deprescribing questionnaire in its original version and adapted to statin use in adults ≥65 years taking a statin for primary prevention. Results: Among the 47 participants (mean age 74.6 years), 42 (89%) were satisfied with their current therapy, but still willing to stop ≥1 of their medications upon their doctor's advice. About 68% (N = 32) were satisfied with their statin therapy, while 83% (N = 39) would accept to consider deprescribing. Twenty-six (55%) participants were concerned about missing future benefits when stopping their general medications and 17 (36%) when stopping their statin. Eight (17%) participants believed they were experiencing side effects of statins and twice as many for general medication (38%, N = 18). Conclusion: Our study provides insight about differences and similarities in patient attitudes toward deprescribing general medications and statins in primary prevention. This information could support patient-centered conversations and shared-decision making about deprescribing.

Process evaluation of a pharmacist-led intervention aimed at deprescribing and appropriate use of cardiometabolic medication among adult people with type 2 diabetes

BACKGROUND

A quasi-experimental study investigated a pharmacist-led intervention aimed at deprescribing and medication management among adult patients with type 2 diabetes at risk of hypoglycaemia.

OBJECTIVE

This study aimed to evaluate the process of implementing the intervention consisting of a tailored clinical medication review (CMR) supported by a training and a toolbox.

METHODS

Mixed-methods study based on the Grant framework, including the domains "recruitment," "delivery of intervention" and "response" of pharmacists and patients. Data collected were administrative logs, semi-structured observations of patient consultations (n = 8), interviews with pharmacists (n = 16) and patient-reported experience measure (PREM) questionnaires (n = 66).

RESULTS

Tailored CMRs were conducted largely as intended for 90 patients from 14 pharmacies. Although patient selection based on a medication-derived hypoglycaemia risk score was considered useful, pharmacists experienced barriers to proposing deprescribing in patients with recent medication changes, without current hypoglycaemic events, or treated by medical specialists. The training and toolbox were evaluated positively by the pharmacists. Overall, patients were satisfied with the CMR.

CONCLUSION

Pharmacists and patients valued the CMR focusing on deprescribing and medication management. To optimize implementation and effectiveness of the intervention, improvements can be made to the patient selection, pharmacist training and the collaboration between healthcare professionals.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home

OBJECTIVES

Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients.

DESIGN

Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing.

SETTING AND PARTICIPANT

Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews.

MEASURES

Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders.

RESULTS

We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing.

CONCLUSIONS AND IMPLICATIONS

Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.