Deprescribing Interventions Research Articles

Deprescribing in hospitalized patients with cancer: A clinical pharmacist-initiated multidisciplinary intervention.

To examine the feasibility and utility of a clinical pharmacist-led multidisciplinary deprescribing intervention in hospitalized cancer patients. We performed a retrospective cohort study among cancer patients hospitalized in oncology department who underwent a medication review by a clinical pharmacist. The pharmacist's recommendations were evaluated by a multidisciplinary team. We collected demographic and clinical information, including information on medication burden before and after intervention and number and types of deprescribing recommendations and their acceptance, and compared them among patients with different estimated life expectancies. During a 2-year study period, 392 patients evaluated by the clinical pharmacist received 2808 prescriptions (median, 7 per patient). The clinical pharmacist recommended deprescribing of 559 medications (19.9%; 95 CI, 18.4-21.4%), at least 1 medication in 321 patients (82%). The multidisciplinary team accepted 89.6% of deprescribing recommendations, resulting in a reduction of the medication burden by 501 medications (P < 0.001). 12.8% of deprescriptions addressed clinically manifested adverse drug effects in 15.1% of patients. The estimation of life expectancy by the senior oncologist was reasonably accurate, but did not affect deprescribing rate. A clinical pharmacist-led deprescribing intervention within a multidisciplinary team effectively reduces medication burden and addresses adverse drug effects in cancer patients. Deprescribing interventions should be incorporated in cancer patients at any stage of the disease.

Use of the Patient Portal to Discuss Medications Among People with Dementia and Their Care Partners.

People with dementia (PWD) often use potentially inappropriate medications (PIM), exposing them to harm. Patient portals are a promising platform for delivering deprescribing educational interventions to reduce PIM use, yet little is known about how PWD and their care partners use patient portals to communicate with clinicians about medications. To characterize the content of patient portal messages relating to medications among PWD, care partners, and clinicians, to inform development of a portal-based intervention to reduce use of PIM among PWD. Descriptive analysis of data from the electronic health record and qualitative analysis of patient portal messages. Adults 65 and older, categorized as having dementia based on EHR algorithm, who received care in an academic health system from 2017 to 2022. Electronic health record data were analyzed using descriptive statistics. Qualitative coding identified topics raised in portal messages. A total of 399 message threads from 159 unique patients were analyzed. Patients were on average 78.4 years old (SD 8.0). Most (65%) were female, White (76%), and non-Hispanic/Latinx (96%); 15% had a registered proxy portal user. The most common topics raised in portal messages were logistics (42%), concerns about adverse effects/treatment burden (25%), asking for new medications (23%), and openness to stopping medications (21%). Qualitative analysis revealed three main themes related to deprescribing: (1) Opportunities to deprescribe, (2) challenges to deprescribing, and (3) medication-related counseling in the portal. PWD and their care partners frequently raise medication concerns in the portal, suggesting it is a promising platform for delivering deprescribing interventions for this population. Future research should identify characteristics of portal-based interventions that would best support deprescribing for PWD and develop pragmatic workflows.

Potential deprescribing indications for antidepressants between 2012 and 2019: repeated cross-sectional analysis in two Scottish health boards

BackgroundAntidepressants have a pivotal role in the treatment of many psychiatric disorders, but there are concerns about long-term use and adverse effects. The objectives of this study were (1) to examine time trends in antidepressant use, (2) to estimate the prevalence of long-term and potential high-risk antidepressant use, and (3) to examine patient characteristics associated with potential deprescribing indications (PDIs) (i.e., simultaneous long-term and potential high-risk antidepressant use).MethodsRepeated population-based cross-sectional study for all 609,299 people aged ≥ 18 years resident in the Tayside or Fife regions of Scotland. The prevalence of antidepressant use was examined on June 30th (index date) of each year from 2012 to 2019, while the prevalence of long-term and potential high-risk use as well as PDIs was assessed and compared on the same dates in 2012 and 2019. Binary logistic regression modeling was used to examine patient characteristics associated with PDIs.ResultsAntidepressant use increased by 27% from 12.0 to 15.3% among adult residents between 2012 and 2019. While the proportion of antidepressants users dispensed ≥ 1 antidepressant for > 2 years increased from 54.3 to 61.9% between 2012 and 2019, the proportion of antidepressant users triggering ≥ 1 indicator of potential high-risk use decreased slightly from 37.9 to 34.7%. In 2019, potential high-risk use most commonly related to indicators targeting fall risk (16.0%), cardiovascular risks (14.1%), insomnia (10.6%), and risk of orthostatic hypotension (8.6%). More than 1 in 4 (25.8%) antidepressant users had PDIs. The main risk factors associated with PDIs included increasing age (65–79, adjusted OR 14.12; 95% CI, 13.15–15.17), increasing number of drugs taken concomitantly (≥ 15 drugs, adjusted OR 7.37; 95% CI, 6.71–8.10), use of tricyclic antidepressants (≥ 50 mg) (adjusted OR 5.49; 95% CI, 5.02–6.01), and concomitant use of ≥ 2 antidepressants (adjusted OR 5.52; 95% CI, 5.20–5.85).ConclusionsLong-term and potential high-risk use of antidepressants is widespread, and potential deprescribing indications (PDIs) are increasing, suggesting the need for a critical review of their ongoing use by clinicians. If deemed necessary, future deprescribing interventions may use the criteria applied here for identification of patients with PDIs and for evaluating intervention effectiveness.

A nurse practitioner-led deprescribing bundled intervention to reduce rates of polypharmacy in the post-acute care setting.

In post-acute care (PAC) settings, residents face elevated risks of adverse drug reactions and emergency department visits because of polypharmacy. With over 90% of PAC residents nationally taking five or more medications, targeted deprescribing of inappropriate or unnecessary medications emerges as a critical strategy. The project site faces high rates of polypharmacy with a root cause analysis revealing a deficiency in evidence-based practices (EBP) for deprescribing potentially inappropriate or unnecessary medications. To address this issue, a bundled deprescribing intervention was implemented as part of a quality improvement project aimed at reducing polypharmacy rates. This project, conducted at a PAC setting in the midwestern United States, used the RE-AIM Model. Data collection involved tracking prescribing rates before and after the intervention for residents admitted to the practice setting over a 5-month period. A bundled EBP intervention comprising a deprescribing framework, pharmacist collaboration, and the utilization of an EBP guideline, established a systematic process guiding deprescribing efforts for each resident on admission to the PAC setting. Fourty-nine patients received a deprescribing bundle, resulting in a 26.67% reduction in prescribed medications. On average, patients had 5.55 medications deprescribed, with reductions noted across 85 distinct therapeutic drug categories. Nurse practitioners play a pivotal role initiating successful deprescribing interventions within the PAC setting. Using a comprehensive approach, integrating pharmacist collaboration and EBP leads to reductions in prescribing rates among PAC residents. This model demonstrates potential for sustainable improvements in patient outcomes within the PAC environment.

Deprescribing: An umbrella review.

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Measuring Quality of Life in Deprescribing Trials: A Scoping Review.

Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions. We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials. We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist. We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear. Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research. Open Science Framework: osf.io/aez6w.

Prescriber Acceptability of a Direct-to-Patient Intervention for Benzodiazepine Receptor Agonist Deprescribing and Behavioural Management of Insomnia in Older Adults.

Behavioural treatments are recommended first-line for insomnia, but long-term benzodiazepine receptor agonist (BZRA) use remains common and engaging patients in a deprescribing consultation is challenging. Few deprescribing interventions directly target patients. Prescribers' support of patient-targeted interventions may facilitate their uptake. Recently assessed in the Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, Sleepwell (mysleepwell.ca) was developed as a direct-to-patient behaviour change intervention promoting BZRA deprescribing and non-pharmacological insomnia management. BZRA prescribers of YAWNS NB participants were invited to complete an online survey assessing the acceptability of Sleepwell as a direct-to-patient intervention. The survey was developed using the seven construct components of the theoretical framework of acceptability (TFA) framework. Respondents (40/250, 17.2%) indicated high acceptability, with positive responses per TFA construct averaging 32.3/40 (80.7%). Perceived as an ethical, credible, and useful tool, Sleepwell also promoted prescriber-patient BZRA deprescribing engagements (11/19, 58%). Prescribers were accepting of Sleepwell and supported its application as a direct-to-patient intervention.

ROOTS TO GROW AND WINGS TO FLY: EDUCATING MEDICINE AND PHARMACY TRAINEES ON VIONE MEDICATION DEPRESCRIBING METHODOLOGY

Abstract An aging world population translates to more chronic illnesses, more medications with potential and relevant cumulative burdens such as non-compliance, adverse outcomes, prescription cascades, confusion, compromised patient safety and quality of life standards. VIONE stands for the 5 filters that categorize medications as Vital, Important, Optional, Not indicated, Every medication has an indication. This is an electronic health record methodology currently implemented in 122 VA facilities across the nation. Physicians and pharmacists review medications, prioritize medications that merit deprescribing interventions, deprescribe through shared decision making and monitor outcomes. In the VA system, within 7 years, we successfully deprescribed over 1.4 million inappropriate medications impacting over 600,000 veterans, used by over 14000 medical providers, with an annualized cost savings of ~ 132 million US dollars. We incorporate VIONE deprescribing education while training our pharmacy residents, medical students, residents and fellows rotating at our VA Medical Center through case based, bed side, didactic and team based multi media learning strategies . The engagement, feedback, demonstrated formal and informal responses remain very promising. Capturing the attention of trainees in their formative years deepens their roots as they spread their wings into practicing safe medication prescribing practices that are current, cutting edge, evidence based and empowering as we train the trainers. We envision medication deprescribing to be part of future academic core curriculum. Our Interdisciplinary team will present compelling data, experiences and outcomes stemming from education of trainees regarding safe medication optimization and deprescribing practices utilizing VIONE methodology that won national and international acclaim.

ANTIHYPERTENSIVE DEPRESCRIBING AND COGNITIVE FUNCTION IN VA NURSING HOME RESIDENTS: A TARGET TRIAL EMULATION

Abstract Deprescribing is the practice of discontinuing or reducing medication that no longer provides benefits or causes harm. While deprescribing antihypertensives for frail elderly patients has gained interest, its impact on patient-centered outcomes such as cognitive function remains unknown. We emulated a target trial involving 45,183 Veteran Affairs nursing home residents aged ≥65 with stays ≥12 weeks between 2006-2019. Eligible residents must have a 4-week stable medication use period; they were allocated to the deprescribing/control arms, and censored at death, discharge, or two-year follow-up for intention-to-treat analysis. We used the Cognitive Function Scale (CFS) to assess cognitive outcomes, categorizing residents into cognitively intact, mild-, moderate-, and severely-impaired groups. We used an ordinal generalized linear-mixed model to analyze the effect of deprescribing on CFS, adjusting for confounders with 47 baseline covariates using inverse probability of the treatment weights. 1,290 and 11,354 patients were in deprescribing/control arms. At baseline, deprescribing was associated with an increased risk of worse cognitive function (OR=1.168 for being in a higher CFS category [95% CI:1.115-1.224]). Overall, cognition worsened in both arms over time (OR=1.007 per week for progression to higher CFS category, 95% CI:1.006-1.008). However, deprescribing mitigated the time trend, and the residents in the deprescribing arm had significantly decreased odds (improved CFS) at 0.996/week (95% CI: 0.995-0.997), 0.900 (95%CI: 0.881-0.919) over 26-weeks, and 0.811 (95% CI: 0.777-0.845) over 52-weeks. Our findings suggest that deprescribing is associated with a slower decline in cognitive function and can help inform future deprescribing interventions for BP management in nursing home residents.

Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment.

Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline. Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes. We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022. We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes. Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results. We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes. There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.

The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials.

Background Polypharmacy is common among older people and may be associated with adverse drug events (ADEs) and poor health outcomes. Pharmacists are well-positioned to reduce polypharmacy and potentially inappropriate medications. Objective The objective of this narrative review was to summarize the results from randomized-controlled trials that evaluated pharmacist-led interventions with the goal or effect to deprescribe medications in older individuals. Data Sources We searched Medline, Embase, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. Data Synthesis Of the 25 studies included, the interventions were conducted in nursing facilities (n = 8), outpatient/community dwellings (n = 8), or community pharmacies (n = 9). Interventions were categorized as comprehensive medication reviews (n = 10), comprehensive medication reviews with pharmacist follow-up (n = 11), and educational interventions provided to patients and/or providers (n = 4). Pharmacist-led interventions had a beneficial effect on 22 out of 32 total medication-related outcomes (eg, number of medications, potentially inappropriate medications, or discontinuation). Most (n = 18) studies reported no evidence of an effect for other outcomes such as health care use, mortality, patient-centered outcomes (falls, cognition, function, quality of life), and ADEs. Discussion Interventions led to improvement in 69% of the medication-related outcomes examined across study settings. Five studies measured ADEs with none accounting for adverse drug-withdrawal events. Large well-designed studies that are powered to find an effect on patient-centered outcomes are needed. Conclusion Pharmacist-led interventions had a significant beneficial effect on medication-related outcomes. There was little evidence of benefit on other outcomes.

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.

Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial.

Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. NCT03984396. Registered on 13 June 2019.

Deprescribing medications among patients with multiple prescribers: A socioecological model.

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

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.

Deprescribing interventions for gabapentinoids in adults: A scoping review.

The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non-randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3months), intermediate (>3 but <12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose-reducing protocols, education and/or pharmacological-based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focused psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area.

Proposing the “continuum of UTI” for a nuanced approach to antimicrobial stewardship

Background: Historically, diagnosis of urinary tract infections (UTIs) has been divided into 3 categories based on symptoms and urine culture results: not UTI, asymptomatic bacteriuria (ASB), or UTI. However, some populations (eg, older adults, catheterized patients) may not present with signs or symptoms referrable to the urinary tract or have chronic lower urinary tract symptoms (LUTS), making the diagnosis of UTI challenging. We sought to understand the clinical presentation of patients who receive urine tests in a cohort of diverse hospitals. Methods: This retrospective descriptive cohort study included all adult noncatheterized inpatient and ED encounters with paired urinalysis and urine cultures (24 hours apart) from 5 community and academic hospitals in 3 states (NC, VA, GA) between January 1, 2017, and December 31, 2019. Trained abstractors collected clinical and demographic data using a 60-question REDCap survey. The study group met with multidisciplinary experts (ID, geriatrics, urology) to define the “continuum of UTI” (Table 1), which includes 2 new categories: (1) LUTS to capture patients with chronic lower urinary tract symptoms and (2) bacteriuria of unclear significance (BUS) to capture patients who do not clinically meet criteria for ASB or UTI (eg, older adults who present with delirium and bacteriuria). The newly defined categories were compared to current guideline-based categories. We further compared ASB, BUS, and UTI categories using a lower bacterial threshold of 1,000 colony-forming units. Results: In total, 220,531 encounters met study criteria. After using a random number generator and removing duplicates, 3,392 encounters were included. Based on current IDSA guidelines, the prevalence of ASB was 32.1% (n = 975), and prevalence of patients with “not UTI” was 1,614 (53%). Applying the expert panel’s new “continuum of UTI” definitions, the prevalence of “not UTI” patients decreased to 1,147 (37.7%), due to reassignment of 467 patients (15.3%)to LUTS. The prevalence of ASB decreased by 24% due to reassignment to BUS. Lowering the bacterial threshold had a slight impact on the number of definitive UTIs (14.9 vs 15.9%) (Table 1). Conclusions: Our rigorous review of laboratory and symptom data from a diverse population dataset revealed that diagnostic uncertainty exists when assessing patients with suspicion for UTI. We propose moving away from dichotomous approach of ASB versus UTI and using the “continuum of UTI” for stewardship conversations. This approach will allow us to develop nuanced deprescribing interventions for patients with LUTS or BUS (eg, watchful waiting, shorter course therapy) that account for the unique characteristics of these populations.Disclosures: None

Multidisciplinary DEprescribing review for Frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement

IntroductionDeprescribing is a strategy for reducing the use of potentially inappropriate medications for older adults. Limited evidence exists on the development of strategies to support healthcare professionals (HCPs) deprescribing for frail older adults in long-term care (LTC). ObjectiveTo design an implementation strategy, informed by theory, behavioural science and consensus from HCPs, which facilitates deprescribing in LTC. MethodsThis study was consisted of 3 phases. First, factors influencing deprescribing in LTC were mapped to behaviour change techniques (BCTs) using the Behaviour Change Wheel and two published BCT taxonomies. Second, a Delphi survey of purposively sampled HCPs (general practitioners, pharmacists, nurses, geriatricians and psychiatrists) was conducted to select feasible BCTs to support deprescribing. The Delphi consisted of two rounds. Using Delphi results and literature on BCTs used in effective deprescribing interventions, BCTs which could form an implementation strategy were shortlisted by the research team based on acceptability, practicability and effectiveness. Finally, a roundtable discussion was held with a purposeful, convenience sample of LTC general practitioners, pharmacists and nurses to prioritise factors influencing deprescribing and tailor the proposed strategies for LTC. ResultsFactors influencing deprescribing in LTC were mapped to 34 BCTs. The Delphi survey was completed by 16 participants. Participants reached consensus that 26 BCTs were feasible. Following the research team assessment, 21 BCTs were included in the roundtable. The roundtable discussion identified lack of resources as the primary barrier to address. The agreed implementation strategy incorporated 11 BCTs and consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site. ConclusionThe deprescribing strategy incorporates HCPs’ experiential understanding of the nuances of LTC and thus addresses systemic barriers to deprescribing in this context. The strategy designed addresses five determinants of behaviour to best support HCPs engaging with deprescribing.

Co-design of a behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe medicines that are no longer needed or are risky to continue in hospital.

Trials of hospital deprescribing interventions have demonstrated limited changes in practitioner behaviour. Our previous research characterised four barriers and one enabler to geriatricians and pharmacists deprescribing in hospital that require addressing by a behaviour change intervention. Six behaviour change techniques (BCTs) have also been selected by the target audience using the hospital Deprescribing Implementation Framework (hDIF). This research aimed to co-design and operationalise the content, mode of delivery and duration/intensity of the six selected BCTs to develop the CompreHensive geriAtRician-led MEdication Review (CHARMER) deprescribing intervention. We established co-design panels at three hospitals representing contextual factors likely to influence CHARMER implementation. Panels comprised geriatricians, pharmacists and other hospital staff likely to be involved in implementation. We convened two rounds of co-design workshops with each hospital to design a prototype for each BCT, which went for feedback at a final workshop attended by all three hospital panels. The six BCTs were co-designed into an intervention comprising:(1&2) Pharmacists' workshop with pros and cons of deprescribing activities, and videos of salient patient cases3 Regular geriatrician and pharmacist deprescribing briefings4 Videos of geriatricians navigating challenging deprescribing consultations5 Hospital deprescribing action plan6 Dashboard to benchmark deprescribing activitiesAutomated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs by stakeholders. These were later excluded as they were not fidelitous to the theoretical determinants of geriatricians' and pharmacists' deprescribing behaviours. This study illustrates the integration of theory and co-design methodology with the target audience and staff likely to be involved in implementation of a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach.

450 Barriers and Enablers to Medication Deprescribing among Older patients attending a Geriatric Clinic in Southwestern Nigeria: A Cross-Sectional Study

Abstract Introduction Polypharmacy is an increasing health problem, leading to rise in morbidity and mortality, especially among older patients. Deprescribing has been recommended for managing polypharmacy, but deprescribing medication in older patients is still uncommon (1). Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy among older patients. However, few empirical data exist on the barriers and enablers to medication deprescribing among older patients in sub-Saharan African countries. Aim This study aimed to assess the barriers and enablers of medication deprescribing among older patients. Methods A cross-sectional study of 415 older patients aged ≥60 years, selected consecutively at the geriatric clinic in a Tertiary Hospital was carried out between May and July 2022. An interviewer-administered semi-structured questionnaire was used to obtain information on their socio-demographic characteristics, and barriers and enablers of medication deprescribing were assessed with modified Revised Patients’ Attitudes Towards Deprescribing (rPATD) Questionnaire (2). Descriptive analyses were carried out using SPSS 23. Results The mean age of the respondents was 69.6 ± 6.4 years and 252 (60.7%) were females. There were 218 (52.5%) respondents with multimorbidity (≥2 medical conditions), and 126 (30.4%) with polypharmacy (≥ 5 medications). Cardiovascular disease 331 (81.0%), and endocrine system disease 111 (26.7%) were the most common disease condition. The enablers to deprescribing were willing to stop one or more regular medicines, if recommended by a physician 251 (60.5%), and willing to stop if the medicines can be restarted in the future if needed 205 (49.4%). While the barriers were would be worried about missing out on medicine benefits 78 (18.8%) and would be reluctant to stop medicines prescribed by a physician 63 (15.2%). Conclusion The older patients were receptive to deprescribing. Satisfaction with medicines and trust in physician’s recommendations are important factors influencing patients’ willingness to have their medicines deprescribed.The most common barrier was worries about missing out on medicine benefits.These findings calls for healthcare professionals to focus on communication strategies to facilitate shared decision-making regarding medication use and deprescribing with patient and family. Improvement in deprescribing through interdisciplinary approach may improve clinical outcomes.