Abstract
BackgroundClass specific deprescribing guidelines could help clinicians taper and stop medications no longer needed or which may be causing more harm than benefit. We set out to develop methodology to create such guidelines using evidence-based methods for guideline development, evidence synthesis and recommendation rating.Methods and FindingsUsing a comprehensive checklist for a successful guideline enterprise, we conducted a national modified Delphi consensus process to identify priorities for deprescribing guidelines, then conducted scoping exercises to identify feasible topics, and sequentially developed three deprescribing guidelines. We selected guideline development team members for clinical expertise; a GRADE member worked with staff to ensure guideline development processes were followed. We conducted or used systematic searches and reviews of deprescribing trials of selected drug classes, reviews or systematic reviews of drug class effectiveness, reviews of reviews of drug class harm and narrative syntheses of contextual questions to inform recommendations and guideline development. Our 8 step process for guideline development included defining scope and purpose, developing a logic model to guide the process and generate key clinical questions, setting criteria for admissible evidence and conducting systematic reviews, synthesizing evidence considering additional contextual information and performing quality estimates, formulating recommendations and providing strength estimations, adding clinical considerations, conducting clinical and stakeholder review and finally updating content pre-publication. Innovative aspects of the guideline development process included synthesizing evidence for outcomes of tapering or stopping medication, and incorporating evidence for medication harm into the recommendation strength rating. Through the development of three deprescribing guidelines (for proton pump inhibitors, benzodiazepine receptor agonists and antipsychotics) and associated decision-support algorithms, we were able to gradually hone the methodology; each guideline will be published separately.ConclusionOur methodology demonstrates the importance of searching for short and long-term outcomes, showing the benefits of deprescribing and studying patient preferences. This publication will support development of future deprescribing guidelines.
Highlights
Little deprescribing guidance is available to clinicians and the public
We selected guideline development team members for clinical expertise; a GRADE member worked with staff to ensure guideline development processes were followed
This article describes the methodology utilized by the team, including methods for prioritization, syntheses of evidence and Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to recommendation process used for this class–specific evidence-based deprescribing initiative
Summary
Current deprescribing algorithms [1,2,3,4] are not class specific and were not developed using a systematic approach. Comprehensive and explicit identification and evaluation of the literature is needed in the development of evidence-based deprescribing guidelines. Our team developed methods, conducted reviews and implemented three evidence-based deprescribing guidelines in six practice sites. This article describes the methodology utilized by the team, including methods for prioritization, syntheses of evidence and Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to recommendation process used for this class–specific evidence-based deprescribing initiative. Class specific deprescribing guidelines could help clinicians taper and stop medications no longer needed or which may be causing more harm than benefit. We set out to develop methodology to create such guidelines using evidence-based methods for guideline development, evidence synthesis and recommendation rating.
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