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Kassis A, Moles R, Carter S. Stakeholders' perspectives and experiences of the pharmacist's role in deprescribing in ambulatory care: A qualitative meta-synthesis. Res Social Adm Pharm 2024; 20:697-712. [PMID: 38685144 DOI: 10.1016/j.sapharm.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Deprescribing is an effective strategy to manage polypharmacy and improve patient outcomes. The notion of a potential role for pharmacists in a multidisciplinary team approach to deprescribing has been identified in quantitative and qualitative literature. However, stakeholders' perceptions of this role, and factors that may impede or facilitate the pharmacist's involvement have not been elucidated. The application in ambulatory care also requires clarification. Understanding stakeholders' views is essential to optimise involvement of the pharmacist in deprescribing and improve practice. OBJECTIVES First, to synthesize the perspectives and experiences of stakeholders (primary care providers, pharmacists, patients, and carers) regarding the role and involvement of the pharmacist in deprescribing in ambulatory care settings. Second, to identify barriers and strategies to enhancing pharmacist involvement in deprescribing. METHODS A systematic search was conducted across CINAHL, Embase, Medline, and Scopus from database inception to April 2023 for qualitative studies in English exploring the pharmacist's role in deprescribing. Data were extracted for iterative and inductive development of themes. A meta-synthesis facilitated the identification of overarching themes. Qualitative secondary analysis enabled identification of barriers and facilitators to the pharmacist's involvement in deprescribing. RESULTS From 285 articles identified, 9 studies were included which explored the views of general practitioners, specialist physicians, pharmacists, nurse practitioners, patients, carers, and general practice and clinic staff as stakeholders in deprescribing in ambulatory care. The meta-synthesis identified 4 over-arching themes: (1) therapeutic impetus and the status quo mentality, (2) role and responsibility, (3) multidisciplinary care, and (4) conflicting interests in pharmacy practice. Strategies to enhance pharmacists' involvement in deprescribing emerged from the data, and the pharmacist's role was strongly encouraged by stakeholders despite logistical and perceptual barriers identified. CONCLUSIONS Incorporation of the strategies to enhance the pharmacist's involvement in deprescribing identified in this review is encouraged to optimise patient-centred care and improve practice.
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Affiliation(s)
- Amanda Kassis
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia.
| | - Rebekah Moles
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Stephen Carter
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, NSW, Australia
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Pierson T, Arcand V, Farrell B, Gagnon CL, Leung L, McCarthy LM, Murphy AL, Persaud N, Raman-Wilms L, Silvius JL, Steinman MA, Tannenbaum C, Thompson W, Trimble J, Sadowski CA, McDonald EG. Proceedings of the Canadian Medication Appropriateness and Deprescribing Network's 2023 National Meeting. Drug Saf 2024:10.1007/s40264-024-01444-2. [PMID: 38884849 DOI: 10.1007/s40264-024-01444-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Tiphaine Pierson
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Verna Arcand
- Kipohtakaw Education Centre, Alexander First Nations, Sturgeon County, AB, Canada
| | - Barbara Farrell
- Bruyėre Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
| | - Camille L Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Larry Leung
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Lisa M McCarthy
- Bruyėre Research Institute, Ottawa, ON, Canada
- University of Waterloo School of Pharmacy, Waterloo, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health and Family Department, Trillium Health Partners, Mississauga, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea L Murphy
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Nav Persaud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
| | - James L Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
- Provincial Seniors Health and Continuing Care, Alberta Health Services, Calgary, AB, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael A Steinman
- University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Cheryl A Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Emily G McDonald
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada.
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Office 3E.03, 5252 De Maisonneuve Blvd, Montreal, QC, H4A3S9, Canada.
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.
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Alyazeedi A, Sherbash M, Algendy AF, Stewart C, Soiza RL, Alhail M, Aldarwish A, Stewart D, Awaisu A, Ryan C, Myint PK. Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults. Healthcare (Basel) 2024; 12:1186. [PMID: 38921300 PMCID: PMC11202920 DOI: 10.3390/healthcare12121186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION To promote optimal healthcare delivery, safeguarding older adults from the risks associated with inappropriate medication use is paramount. OBJECTIVE This study aims to evaluate the effectiveness of implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in ambulatory older adults to enhance medication safety. METHOD The QTRIM was developed by an expert consensus panel using the Beers Criteria and contained a list of potentially inappropriate medications (PIMs) based on the local formulary. Using quality improvement methodology, it was piloted and implemented in two outpatient pharmacy settings serving geriatric medicine and dermatology clinics at Rumailah Hospital, Qatar. Key performance indicators (KPIs) using implementation documentation as a process measure and the percentage reduction in PIM prescriptions as an outcome measure were assessed before and after QTRIM implementation. This study was conducted between July 2022 and September 2023. RESULTS In the outpatient department (OPD) geriatric pharmacy, the prescription rate of PIMs was reduced from an average of 1.2 ± 0.7 PIMs per 1000 orders in 2022 to an average of 0.8 ± 0.2 PIMs per 1000 orders in 2023. In the OPD geriatric pharmacy, the results showed a 66.6% reduction in tricyclic antidepressants (TCAs) (from 30 to 10), a reduction in first-generation antihistamines by 51.7% (29 to 14), and muscle relaxants by 33.3% (36 to 24). While in dermatology, the older adult prescription rate of PIMs was reduced from an average of 8 ± 3 PIMs per 1000 orders in 2022 to a rate of 5 ± 3 PIMs per 1000 orders in 2023; the most PIM reductions were (49.4%) in antihistamines (from 89 to 45), while muscle relaxants and TCAs showed a minimal reduction. CONCLUSIONS Implementing QTRIM with pharmacy documentation monitoring markedly reduced the PIMs dispensed from two specialized outpatient pharmacies serving older adults. It may be a promising effective strategy to enhance medication safety in outpatient pharmacy settings.
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Affiliation(s)
- Ameena Alyazeedi
- Pharmacy Department, Rumailah Hospital, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar; (M.S.); (A.F.A.)
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK; (C.S.); (R.L.S.); (P.K.M.)
| | - Mohamed Sherbash
- Pharmacy Department, Rumailah Hospital, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar; (M.S.); (A.F.A.)
| | - Ahmed Fouad Algendy
- Pharmacy Department, Rumailah Hospital, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar; (M.S.); (A.F.A.)
| | - Carrie Stewart
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK; (C.S.); (R.L.S.); (P.K.M.)
| | - Roy L. Soiza
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK; (C.S.); (R.L.S.); (P.K.M.)
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen University, Aberdeen AB25 2ZN, Scotland, UK
| | - Moza Alhail
- Pharmacy Executive Director’s Office, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Abdulaziz Aldarwish
- Rumailah Administration, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Derek Stewart
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (D.S.); (A.A.)
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (D.S.); (A.A.)
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, D02 PN40 Dublin, Ireland;
| | - Phyo Kyaw Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK; (C.S.); (R.L.S.); (P.K.M.)
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen University, Aberdeen AB25 2ZN, Scotland, UK
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Stuijt PJC, Heringa M, van Dijk L, Faber A, Burgers JS, Feenstra TL, Taxis K, Denig P. Effects of a multicomponent communication training to involve older people in decisions to DEPRESCRIBE cardiometabolic medication in primary care (CO-DEPRESCRIBE): protocol for a cluster randomized controlled trial with embedded process and economic evaluation. BMC PRIMARY CARE 2024; 25:210. [PMID: 38862899 PMCID: PMC11165805 DOI: 10.1186/s12875-024-02465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients. METHODS A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted. DISCUSSION The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (identifier: NCT05507177).
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Affiliation(s)
- Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Adrianne Faber
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| | - Jako S Burgers
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Dutch National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, - Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, PO-Box 30001, HPC AP50, UMCG, Groningen, 9700RB, The Netherlands.
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Farrell B. Engaging patients in conversations about deprescribing. Expert Rev Clin Pharmacol 2024; 17:419-422. [PMID: 38618915 DOI: 10.1080/17512433.2024.2343913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/12/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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Schuster BG, Faisal S, L Gagnon C. A new curricular framework for an interprofessional approach to deprescribing: Why and how pharmacists should lead the way. Can Pharm J (Ott) 2024; 157:101-103. [PMID: 38737361 PMCID: PMC11086733 DOI: 10.1177/17151635241239924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/09/2023] [Indexed: 05/14/2024]
Affiliation(s)
| | - Sadaf Faisal
- Research Centre, Institut universitaire de gériatrie de Montréal
| | - Camille L Gagnon
- Research Centre, Institut universitaire de gériatrie de Montréal
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McDonald EG, Lundby C, Thompson W, Boyd C, Farrell B, Gagnon C, Herbin J, Khuong N, Moriarty F, Pierson T, Scott S, Scott IA, Silvius J, Spinewine A, Steinman MA, Tannenbaum C, Trimble J, Turner JP, Reeve E. Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks. Expert Rev Clin Pharmacol 2024; 17:433-440. [PMID: 38739460 DOI: 10.1080/17512433.2024.2355270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Carina Lundby
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology in the School of Medicine, the Center on Aging and Health, and the departments of Epidemiology and Health Policy and Management at Johns Hopkins University in Baltimore, Baltimore, MD, USA
| | - Barbara Farrell
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Jennie Herbin
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ninh Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tiphaine Pierson
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - Ian A Scott
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jim Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Provincial Seniors Health & Continuing Care, Alberta Health Services, Alberta, Canada
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group UCLouvain, Brussels, Belgium
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Cara Tannenbaum
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Johanna Trimble
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Quebec, Canada
| | - Justin P Turner
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Melbourne, SA, Australia
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
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.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Radcliffe E, Servin R, Cox N, Lim S, Tan QY, Howard C, Sheikh C, Rutter P, Latter S, Lown M, Brad L, Fraser SDS, Bradbury K, Roberts HC, Saucedo AR, Ibrahim K. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatr 2023; 23:591. [PMID: 37743469 PMCID: PMC10519081 DOI: 10.1186/s12877-023-04256-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
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.
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Affiliation(s)
- Eloise Radcliffe
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK.
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK.
| | - Renée Servin
- Faculty of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Natalie Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Stephen Lim
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Qian Yue Tan
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Clare Howard
- Wessex Academic Health Science Network, Science Park, Chilworth, Southampton, UK
| | - Claire Sheikh
- Hampshire and Isle of Wight Integrated Care Board, Southampton, UK
| | - Paul Rutter
- School of Pharmacy and Biomedical Sciences, Portsmouth University, Portsmouth, UK
| | - Sue Latter
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Mark Lown
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Lawrence Brad
- Westbourne Medical Centre, Westbourne, Bournemouth, UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton Foundation Trust, Southampton, UK
| | - Katherine Bradbury
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- School of Psychology, University of Southampton, Southampton, UK
| | - Helen C Roberts
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton Foundation Trust, Southampton, UK
| | - Alejandra Recio Saucedo
- School of Healthcare Enterprise and Innovation, Trials and Studies Coordinating Centre, National Institute of Health Research Evaluation, University of Southampton, Southampton, UK
| | - Kinda Ibrahim
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
- NIHR Applied Research Collaboration ARC Wessex, University of Southampton, Southampton, UK
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
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