Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action.

© The Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. Background: Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods: The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results: By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-intraining often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions: This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

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Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review.

Prescribing of potentially inappropriate medications (PIMs) that pose more risk than benefit in older patients is a common occurrence across all healthcare settings. Reducing such prescribing has been challenging despite multiple interventions, including educational campaigns, audits and feedback, geriatrician assessment and formulary restrictions. With the increasing uptake of electronic medical records (EMRs) across hospitals, clinics and residential aged care facilities (RACFs), integrated with computerized physician order entry (CPOE) and e-prescribing, opportunities exist for incorporating clinical decision support systems (CDSS) into EMR at the point of care. This narrative review assessed the process and outcomes of using EMR-enabled CDSS to reduce the prescribing of PIMs. We searched PubMed for relevant articles published up to January 2018 and focused on those that described EMR-enabled CDSS that assisted prescribers to make changes at the time of ordering PIMs in adults. Computerized systems offering only medication reconciliation, dose checks, monitoring for medication errors, or basic formulary information were not included. In addition to outcome measures of medication-related processes and adverse drug events, qualitative data relating to factors that influence effectiveness of EMR-enabled CDSS were also gathered from selected studies. We analysed 20 studies comprising 10 randomized trials and 10 observational studies performed in hospitals (n = 8), ambulatory care clinics (n = 9) and RACFs (n = 3). Studies varied in patient populations (although most involved older patients), type of CDSS, method of linkage with EMR, study designs and outcome measures. However, assuming little publication bias, the totality of evidence favoured EMR-enabled CDSS as being effective in reducing the prescribing of PIMs in hospitals, although results were more mixed for ambulatory care settings and RACFs. While absolute effects in most positive studies were modest, they suggest EMR-enabled CDSS are feasible and acceptable to clinicians, and if certain design features are adhered to, there is potential for even greater impact.

https://journals.sagepub.com/doi/pdf/10.1177/2042098618784809

Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review:

Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.

A systems approach to identifying the challenges of implementing deprescribing in older adults across different health care settings and countries: a narrative review

Background Falls are a common cause of morbidity and hospitalisation in older people. Inappropriate prescribing and polypharmacy contribute to falls risk in elderly patients. This study9s aim was to quantify the problem and find out if medication review in the hospital setting led to deprescribing of medicines associated with falls risk. Methods Admissions records for elderly patients were examined to identify those whose presenting complaint included a fall. Inpatient medication charts, pharmaceutical care notes, medical notes and discharge summaries were examined to identify any falls-risk medicines from admission histories and to determine if any medication review took place, and whether or not changes were made as a result. In particular deprescribing and dose reduction details were analysed. Results 100 patients over 70 years old were admitted following a fall during the 2 months study period. The mean number of medicines on admission was 6.8 per patient with polypharmacy found in 62/100 (62%). One or more falls-risk medicine was found in 65/100 (65%) patients. Medicines review was carried out in 86/100 (86%) of patients, and 59/697 (8.5%) medicines were deprescribed. Pharmacist involvement in medication review led to a significant reduction in the number of falls-risk medicines per patient (p=0.002). Conclusions Inappropriate prescribing and polypharmacy are found frequently in elderly patients at admission following a fall. Comprehensive medicines reviews should be carried out in all such patients with the objective of deprescribing or reducing doses to minimise risk of harm. Involvement of a pharmacist improves the rate of reduction of falls-risk medicines.

https://ejhp.bmj.com/content/ejhpharm/24/1/10.full.pdf

Deprescribing medicines in the acute setting to reduce the risk of falls

Objectives Our aim was to explore junior doctors’ attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. Method An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. Results Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacist’s duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. Conclusions Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a ‘bottom-up’ educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

https://ejhp.bmj.com/content/ejhpharm/22/4/243.full.pdf

A pilot survey of junior doctors' attitudes and awareness around medication review: time to change our educational approach?

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults’ medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily “hold” medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.

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Improving Pharmacists’ Targeting of Patients for Medication Review and Deprescription

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Iñaki Bovill

Papers

A pilot survey of junior doctors' attitudes and awareness around medication review: time to change our educational approach?

Improving Pharmacists’ Targeting of Patients for Medication Review and Deprescription

Stopping Inappropriate Medicines in the Outpatient Setting