Deprescribing In Patients Research Articles

P-1734. Pharmacist-Led Antibiotic Deprescribing for Negative Urine Cultures in the Emergency Department

Abstract Background Inappropriate antibiotic use in EDs, often due to empiric prescribing before urine culture results are available, poses significant challenges. This study evaluates the impact of a pharmacist-led intervention to deprescribe antibiotics for patients with negative urine culture results. Intervention Methods Conducted from May 1, 2023, to March 31, 2024, this study employed a two-phase approach involving a retrospective review and a prospective intervention. Inclusion criteria were patients prescribed antibiotics for a UTI with subsequent negative urine culture results during an ED visit. Exclusion criteria included patients admitted for inpatient treatment or transferred to other healthcare facilities. In Phase I (May to July 2023), a clinical pharmacist in the ED adjusted antibiotic therapy based on culture susceptibility results on weekdays. Phase II (January to March 2024) expanded to include antibiotic deprescribing in patients with negative results. The primary outcome was the number of ED readmissions within 30 days after antibiotic discontinuation for UTI symptoms or serious infection. Secondary outcomes included total antibiotic days saved, antibiotic days prescribed per patient at ED discharge, and post-intervention antibiotic days per patient. Statistical analyses utilized the Fisher Exact Test and Mann-Whitney U Test. Patient Characteristics Results The study included 78 patients: 27 in the retrospective phase and 51 in the prospective phase. Among the initial 51 patients, follow-ups with 17 revealed no continued UTI symptoms. There were no readmissions in our prospective intervention group compared to two in the retrospective group (P=0.117). Antibiotic days were significantly reduced from a pre-intervention average of 7.2 to 5.2 days per patient post-intervention (P=0.000468), saving a total of 82 antibiotic days. Results Conclusion Pharmacist-led deprescribing of antibiotics in patients with negative urine cultures significantly reduced total antibiotic days per patient without increasing ED readmissions for urinary tract infection symptoms. These findings demonstrate the feasibility and safety of deprescribing in a clinical ED setting and suggest potential changes in clinical practice, advocating for the expansion of pharmacist roles in antibiotic stewardship programs. Results Continued Disclosures All Authors: No reported disclosures

Determinants of successful opioid deprescribing: Insights from French pain physicians-A qualitative study.

Long-term use of opioids does not result in significant clinical improvement and has shown more adverse than beneficial effects in chronic pain conditions. When opioids cause more adverse effects than benefits for the patient, it may be necessary to initiate a process of deprescribing. To explore the perceptions of French pain physicians regarding the process of opioid deprescribing in patients experiencing chronic non-cancer and to generate an understanding of the barriers and levers to the deprescribing process. We conducted a multicentric observational study with qualitative approach. Individual semi-structured interviews exploring pain physicians' perceptions, beliefs, and representations to assess the determinants of opioid deprescribing with an interview guide were used. After checking the transcripts, an inductive and independent thematic analysis of the interviews was to extract meaningful themes from the dataset. Twelve pain physicians were interviewed. The main obstacles to deprescribing revolved around patient-specific attributes, characteristics of the opioids themselves, and limitations within the current healthcare system, that hinder optimal patient management. Conversely, patient motivation and education, recourse to hospitalization in a Pain Department with multidisciplinary care, follow-up by the general practitioner, and training and information dissemination among patients and clinicians emerged as facilitative elements for opioid deprescribing. This study underscores the needs to improve the training of healthcare professionals, the effective communication of pertinent information to patients, and the establishment of a therapeutic partnership with the patient. It is therefore essential to carry out the deprescribing process in a collaborative and interprofessional manner, encompassing both pharmaceutical and non-pharmaceutical strategies.

Deprescribing in older adults in a French community: a questionnaire study on patients’ beliefs and attitudes

BackgroundGeneral practitioners (GPs) have a central role to play on reduction of polypharmacy and deprescribing. This study aimed to assess beliefs and attitudes towards deprescribing in patients, aged 65 years or older in primary care, and to identify factors associated with deprescribing and their willingness to stop medication.MethodsA questionnaire study was performed between 23 May and 29 July 2022 on patients aged 65 years or older attending a GP’s surgery in a French area. We used the French version of the revised Patients’ Attitudes Towards Deprescribing self-report questionnaire (rPATD), which measures four subscales (“Burden”, “Appropriateness”, “Concerns about stopping” and, “Involvement”), patients’ willingness to stop one of their regular medicines, and patients’ satisfaction with their current medicines.ResultsThe study enrolled 200 patients. Median age was 76 years old (IQR 71–81), 55% were women, and 42.5% took 5 or more medications per day. Although most patients (92.5%) were satisfied with their current medicines, 35% were reluctant to stop medications they had been taking for a long time, and 89.5% were willing to stop medication if asked to by their GP. Patients aged less than 75 years old reported more concerns about stopping. Women and patients with higher educational attainment showed significantly higher involvement in medication management.ConclusionsThe majority of older adults were willing to stop one or more of their regular medicines if asked to do so by their GP. GPs should address deprescribing into their current practice.

Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study

Patients treated with dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (eg, falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medication reviews, it can be complex and time-consuming. Whether clinical decision support improves the process and increases deprescribing for patients treated with dialysis is unknown. This study aimed to test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients treated with dialysis. Prospective controlled quality improvement study with a contemporaneous control. Patients prescribed≥5 medications in 2 outpatient dialysis units in Montréal, Canada. Patient health data from the electronic medical record were input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists in the intervention unit additionally received deprescribing reports, and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. In the control unit, patients received usual care alone. The proportion of patients with≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the effect of using MedSafer. The absolute risk difference with 95% CI and number needed to treat were calculated. The primary outcome was the proportion of patients with one or more PIMs deprescribed. Secondary outcomes include the reduction in the mean number of prescribed drugs and PIMs from baseline. In total, 195 patients were included (127, control unit; 68, intervention unit); the mean age was 64.8±15.9 (SD), and 36.9% were women. The proportion of patients with≥1 PIMs deprescribed in the control unit was 3.1% (4/127) vs 39.7% (27/68) in the intervention unit (absolute risk difference, 36.6%; 95% CI, 24.5%-48.6%; P<0.0001; number needed to treat=3). This was a single-center nonrandomized study with a type 1 error risk. Deprescribing durability was not assessed, and the study was not powered to reduce adverse drug events. Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed.

Exploring the facilitators and barriers in opioid deprescribing for non-cancer pain treatment experienced by general practitioners: A qualitative study.

Guidelines recommend opioid deprescribing in patients on long-term opioid treatment for chronic non-cancer pain. This study aims to explore facilitators and barriers in opioid deprescribing among general practitioners in the Netherlands. In addition, this study aims to identify possibilities for improvement regarding opioid deprescribing in primary care. Focus group discussions with Dutch General practitioners were held by two skilled moderators. The focus group discussions were transcribed verbatim and analysed using MAXQDA software. Three independent reviewers searched for overarching themes using thematic analysis with an inductive approach. Discussions were organized until data saturation was reached. Twenty-two general practitioners participated in four focus group discussions. Five main themes emerged from the data: (1) patient-centred care; (2) ensuring proper pain management (3) dilemmas and hardships in dealing with opioid use disorder; (4) the competency gap; (5) needs and possibilities to improve opioid deprescribing in primary care. The first theme addresses the main facilitators in opioid tapering. The following three themes emerged as main barriers in opioid deprescribing. The fifth theme identified possibilities for change. This study indicates the importance of intrinsic motivation and a tailored approach to deprescribe opioids in patients with chronic pain on long-term opioid treatment. Identified barriers include struggles in pain management, challenges caused by opioid use disorder, insufficient capacities such as time constraints and lack of skills. Recommendations for improvement involve enhanced collaboration with healthcare professionals in primary and secondary care, provision of practical tools and assurance of sufficient time. This focus group study among 22 Dutch general practitioners elucidates the complexities of opioid deprescribing and reveals pivotal themes such as patient-centred care, pain management challenges, and competency gaps. The findings underscore the crucial role of intrinsic motivation and that of a tailored approach in opioid deprescribing, while demonstrating how a lack in effective pain treatments, practical capacities and challenges caused by opioid dependence, impede opioid deprescribing. By uncovering these complexities, this study aims to inform future deprescribing strategies.

Barriers and facilitators to opioid deprescribing among Advanced Nurse Practitioners: A qualitative interview study.

To explore the experiences primary care Advanced Nurse Practitioners have had in relation to deprescribing opioids in chronic non-malignant pain. A qualitative interview study. Primary care Advanced Nurse Practitioners were recruited from across the Northern Ireland GP Federations. Data collection for this study took place between April and June 2022. In total, 10 semi-structured online interviews were conducted. Interviews were audio and visually recorded, transcribed verbatim and interpreted using a thematic analysis framework. The COREQ criteria were used to guide the reporting of this study. The Advanced Nurse Practitioners experienced several challenges associated with opioid deprescribing and the implementation of current chronic pain guidelines. The main barriers identified were difficulties engaging patients in deprescribing discussions, a lack of availability of supportive therapies and poor access to secondary care services. The barriers identified directly impacted on their ability to deliver best practice which resulted in a sense of professional powerlessness. The experiences of the Advanced Nurse Practitioners demonstrate that opioid deprescribing in patients with chronic pain is challenging, and implementation of current chronic pain guidelines is difficult. This study contributes to existing literature on the topic of reducing opioid prescribing and as far as the authors are aware, is the first study to examine the experiences of primary care advanced nurse practitioners in this context. These findings will be of interest to other primary care practitioners, and prescribers involved in the management of chronic non-malignant pain. No patient or public contribution.

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

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. 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. 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). 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. 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.

Aspirin deprescribing in patients on oral anticoagulation for atrial fibrillation or venous thromboembolism: A national survey of clinician practices

AbstractIntroductionConcomitant use of oral anticoagulation (OAC) and aspirin increases bleeding risk without decreasing thromboembolic events compared with OAC monotherapy. Weak guideline recommendations and limited data exist for deprescribing aspirin for primary prevention or stable coronary artery disease in patients already on OAC for atrial fibrillation (AF) or venous thromboembolism (VTE).ObjectivesThe objective of this study was to identify aspirin deprescribing practices among clinicians for patients on OAC for AF or VTE and concomitant aspirin for non‐compelling reasons.MethodsA cross‐sectional, national survey was electronically distributed to pharmacists and non‐pharmacists (physicians, nurse practitioners, physician assistants). Co‐primary end points were composite aspirin discontinuation rates in patients on OAC for AF or VTE in primary prevention and stable coronary artery disease (CAD) cases. Key secondary end points were clinician comfort level with deprescribing aspirin and availability of institutional protocols.ResultsThree hundred four responses were included: 212 (69.7%) pharmacists and 92 (30.3%) non‐pharmacists. Mean age of respondents was 35.4 years, and 37.4% male. In the primary prevention cases, pharmacists were more likely to discontinue aspirin than non‐pharmacists (76.7% vs. 54.6%, p &lt; 0.001). In the stable CAD cases, composite rates of aspirin discontinuation by pharmacists and non‐pharmacists were similar (41.7% vs. 40.1%, p = 0.140). More pharmacists than non‐pharmacists stated that their aspirin deprescribing decisions were independent of the type of OAC that was used (60.4% vs. 35.9%, p &lt; 0.001). Pharmacists were more likely to discontinue aspirin after discussing with patients compared with non‐pharmacists (62.7% vs. 47.8%, p = 0.017). 27.3% of clinicians reported having a protocol to deprescribe aspirin at their institution/clinic.ConclusionThere are variations in aspirin deprescribing practices among clinicians in patients on OAC for AF or VTE and without compelling indications for aspirin. Further studies and stronger recommendations are warranted to guide clinicians regarding optimal antithrombotic therapy in these scenarios. Lack of institutional protocols for aspirin deprescribing creates opportunities for future quality improvement initiatives.

Deprescribing in the Home Palliative Setting.

Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.

Evaluating an inpatient deprescribing initiative at a rural community hospital in Ontario.

Deprescribing is an effective means to reduce polypharmacy in elderly patients. However, geriatric day care deprescribing services are challenging to implement in rural regions. In this study, we examined whether a subacute care unit of a rural hospital could deliver a comprehensive and multidisciplinary intervention to promote deprescribing in patients and whether this intervention would succeed in achieving significant and lasting deprescribing results. We conducted a cross-sectional analysis of a deprescribing program at a rural hospital in Eastern Ontario, Canada. Participants were 11 patients, aged 65 or older, who were admitted to the hospital's medical/surgical unit or who presented to the emergency department. Clinicians followed a structured, comprehensive and multidisciplinary approach designed to facilitate deprescribing, which concluded with an outcome evaluation at discharge and follow-up phone calls. Outcomes included the frequency and total number of medications successfully removed, reduced, substituted and restarted after discharge and emergency department visits and hospitalizations 6 months before and after the intervention. Of a total 57 deprescribed medications, 38 were eliminated, 8 were switched to a safer alternative, and 11 were dose reduced. Postdischarge deprescribing reversal occurred in only 5 of 57 deprescribed medications. Among the study population, a 59.2% reduction was observed in the combined number of emergency department visits and hospitalizations 6 months after deprescribing. This feasibility study was successful in showing the potential added value for offering a rehabilitative, subacute care, inpatient, comprehensive and multidisciplinary approach toward patients with complex deprescribing needs. It also showed proof of concept in reducing polypharmacy-induced adverse health outcomes. Can Pharm J (Ott) 2020:153:xx-xx.

Validation of the LESS-CHRON criteria: reliability study of a tool for deprescribing in patients with multimorbidity

ObjectiveThe ‘LESS-CHRON criteria’ (List of Evidence-Based Deprescribing for Chronic Patients criteria) is a newly created tool with 27 criteria to guide deprescribing. It was developed using a Delphi methodology. Each...

Medication Safety, Adherence, and Deprescribing in Patients With Dementia.

Patients with dementia face challenges with medication adherence because of the nature of the disease. Not only is adherence difficult in individuals with dementia, but the majority of this patient population also has comorbidities that make comprehension of complex treatment plans difficult. A large analysis of patients with dementia showed that 12% had only dementia as a diagnosis, 70% had at least two comorbidities, and 48% had at least three comorbidities. Proper medication adherence is important to prevent progression of these comorbidities and decline in overall health. However, as dementia progresses, the risk of taking certain medications may outweigh the benefits. Therefore, the treatment team needs to reassess medication lists over time. Incorrect medication use can pose a major safety concern for this patient population. Pharmacists can have conversations with patients and the patients' family members to discuss goals of care to determine if deprescribing is an option.