暂无摘要。

BACKGROUND: Collaboration between physicians and pharmacists facilitates the conduct of medication optimisation efforts. In the context of deprescribing, pharmacists\' roles are often described as making deprescribing recommendations to physicians. Little is known about factors associated with pharmacists\' willingness to make deprescribing recommendations and their interprofessional collaboration with physicians in Swiss primary care settings.
OBJECTIVE: To explore pharmacists\' perspectives on medication optimisation and deprescribing in older adults, and their preferences for interprofessional collaboration in Swiss primary care settings.
METHODS: In this cross-sectional study, a random sample of 1000 pharmacist members of the Swiss Pharmacists Association pharmaSuisse was invited to participate in a survey on medication optimisation, deprescribing, and interprofessional collaboration. The survey contained three case vignettes of multimorbid patients with polypharmacy aged ≥ 80 years old, with different levels of dependency in activities in daily living (ADL) and cardiovascular disease (CVD). For each case vignette, pharmacists were asked if and which medications they would deprescribe. We calculated proportions of pharmacists\' willingness to deprescribe by case vignette and performed a multilevel logistic regression to assess associations between CVD, ADL, and willingness to deprescribe.
RESULTS: One hundred thirty-eight (14%) pharmacists responded to the survey: 113 (82%) were female, their mean age was 44 years (SD = 11), and 66% (n = 77) reported having never received any specific training on how to conduct structured medication reviews. Eighty-three (72%) pharmacists reported to be confident in identifying deprescribing opportunities. All pharmacists were willing to deprescribe ≥ 1 medication in all vignettes. Patients with CVD were at lower odds of having medications deprescribed (OR = 0.27, 95%CI 0.21 to 0.36). Willingness to deprescribe was lower with higher dependency in ADL (medium versus low dependency: OR = 0.68, 95%CI 0.54 to 0.87, high versus low dependency: OR = 0.72, 95%CI 0.56 to 0.91). However, the effect of dependency in ADL on willingness to deprescribe was significantly modified by the history of CVD. One hundred five pharmacists (97%) reported to interact with physicians to clarify questions regarding prescriptions at least once a week and 88 (81%) wished to be more involved in deprescribing and medication review.
CONCLUSIONS: Pharmacists were willing to make deprescribing suggestions for older patients with polypharmacy, but two-thirds reported having received no formal training on how to perform structured medication reviews. Pharmacists would like to be more involved in the process of medication review and deprescribing, which should be leveraged in the context of Swiss primary care settings.

暂无摘要。

UNASSIGNED: High-risk medications that contribute to adverse health outcomes are frequently prescribed to older adults. Deprescribing interventions reduce their use, but studies are often not designed to examine effects on patient-relevant health outcomes.
UNASSIGNED: To test the effect of a health system-embedded deprescribing intervention targeting older adults and their primary care clinicians for reducing the use of central nervous system-active drugs and preventing medically treated falls.
UNASSIGNED: In this cluster randomized, parallel-group, clinical trial, 18 primary care practices from an integrated health care delivery system in Washington state were recruited from April 1, 2021, to June 16, 2022, to participate, along with their eligible patients. Randomization occurred at the clinic level. Patients were community-dwelling adults aged 60 years or older, prescribed at least 1 medication from any of 5 targeted medication classes (opioids, sedative-hypnotics, skeletal muscle relaxants, tricyclic antidepressants, and first-generation antihistamines) for at least 3 consecutive months.
UNASSIGNED: Patient education and clinician decision support. Control arm participants received usual care.
UNASSIGNED: The primary outcome was medically treated falls. Secondary outcomes included medication discontinuation, sustained medication discontinuation, and dose reduction of any and each target medication. Serious adverse drug withdrawal events involving opioids or sedative-hypnotics were the main safety outcome. Analyses were conducted using intent-to-treat analysis.
UNASSIGNED: Among 2367 patient participants (mean [SD] age, 70.6 [7.6] years; 1488 women [63%]), the adjusted cumulative incidence rate of a first medically treated fall at 18 months was 0.33 (95% CI, 0.29-0.37) in the intervention group and 0.30 (95% CI, 0.27-0.34) in the usual care group (estimated adjusted hazard ratio, 1.11 (95% CI, 0.94-1.31) (P = .11). There were significant differences favoring the intervention group in discontinuation, sustained discontinuation, and dose reduction of tricyclic antidepressants at 6 months (discontinuation adjusted rate: intervention group, 0.23 [95% CI, 0.18-0.28] vs usual care group, 0.13 [95% CI, 0.09-0.17]; adjusted relative risk, 1.79 [95% CI, 1.29-2.50]; P = .001) and secondary time points (9, 12, and 15 months).
UNASSIGNED: In this randomized clinical trial of a health system-embedded deprescribing intervention targeting community-dwelling older adults prescribed central nervous system-active medications and their primary care clinicians, the intervention was no more effective than usual care in reducing medically treated falls. For health systems that attend to deprescribing as part of routine clinical practice, additional interventions may confer modest benefits on prescribing without a measurable effect on clinical outcomes.
UNASSIGNED: ClinicalTrials.gov Identifier: NCT05689554.

BACKGROUND: Older patients with type 2 diabetes mellitus (T2D) have an increased risk of hypoglycaemic episodes when using sulphonylureas or insulin. In the Netherlands, guidelines exist for reducing glucose-lowering medication in older patients. However, evidence is lacking that a medication reduction in older patients can be safely pursued. Here, we will examine if promoting the deprescribing of insulin/sulphonylureas with a deprescribing programme (DPP) in general practice affects T2D-complications in older overtreated patients.
METHODS: We will perform a 1:1 cluster randomised controlled trial in 86 general practices in the Netherlands. The DPP will consist of education sessions with general practitioners and practice nurses about reducing glucose-lowering medication in older patients (≥ 70 years). Topics of the sessions include the necessity of deprescribing, tools to initiate deprescribing and strategies to discuss deprescribing with patients (shared decision making). The DPP further includes a support programme with practice visits. The study will employ a selection tool to identify possibly overtreated older patients from the electronic medical records of the general practitioner. Eligibility for enrolment in the study will be based on HbA1c targets indicated by the Dutch guidelines, which depend on age, diabetes duration, presence of frailty, and life expectancy. The control group will provide usual care. We aim to include 406 patients. The follow-up period will be 2 years. For the primary outcome, the effect of the DPP on T2D-complications will be assessed by counting the cumulative incidence of events related to under- and overtreatment in T2D as registered in the electronic medical records. We shall perform an intention-to-treat analysis and an analysis including only patients for whom deprescribing was initiated. The implementation of the DPP in general practice will be evaluated quantitatively and qualitatively using the Extended Normalisation Process Theory (ENPT) and the Reach, Efficacy - Adoption, Implementation and Maintenance (RE-AIM) model. Other secondary outcomes include quality of life, cognitive functioning, events related to overtreatment or undertreatment, biomarkers of health, amount of blood glucose-lowering medication prescriptions, and cost-effectiveness.
CONCLUSIONS: This study will provide insight into the safety and feasibility of a programme aimed at deprescribing sulphonylureas/insulin in older people with T2D who are treated in general practice.
BACKGROUND: ISRCTN Registry, ISRCTN50008265 , registered 09 March, 2023.

BACKGROUND: Potentially inappropriate medication remains a significant concern in general practices, particularly in the context of overactive bladder (OAB) treatment for individuals aged 65 years and older. This study focuses on the exploration of alternative options for treating OAB and the deprescribing of anticholinergic drugs commonly used in OAB. The research aims to comprehensively evaluate the efficiency of deprescribing through a mixed methods approach, combining quantitative assessment and qualitative exploration of perceptions, experiences, and potential barriers among patients and health care personnel.
OBJECTIVE: This study aims to evaluate the efficiency and safety of the intervention in which health care staff in primary care encourage patients to participate in deprescribing their drugs for OAB. In addition, we aim to identify factors contributing to or obstructing the deprescribing process that will drive more informed decisions in the field of deprescribing and support effective and safe treatment of patients.
METHODS: The drugs for overactive bladder in primary care (DROP) study uses a rigorous research design, using a randomized controlled trial (RCT) with an embedded sequential explanatory mixed methods approach. All general practices within the North Denmark Region will be paired based on the number of general practitioners (GPs) and urban or rural locations. The matched pairs will be randomized into intervention and control groups. The intervention group will receive an algorithm designed to guide the deprescribing of drugs for OAB, promoting appropriate medication use. Quantitative data will be collected from the RCT including data from Danish registries for prescription analysis. Qualitative data will be obtained through interviews and focus groups with GPs, staff members, and patients. Finally, the quantitative and qualitative findings are merged to understand deprescribing for OAB comprehensively. This integrated approach enhances insights and supports future intervention improvement.
RESULTS: The DROP study is currently in progress, with randomization of general practices underway. While they have not been invited to participate yet, they will be. The inclusion of GP practices is scheduled from December 2023 to April 2024. The follow-up period for each patient is 6 months. Results will be analyzed through an intention-to-treat analysis for the RCT and a thematic analysis for the qualitative component. Quantitative outcomes will focus on changes in prescriptions and symptoms, while the qualitative analysis will explore experiences and perceptions.
CONCLUSIONS: The DROP study aims to provide an evidence-based intervention in primary care that ensures the deprescription of drugs for OAB when there is an unfavorable risk-benefit profile. The DROP study\'s contribution lies in generating evidence for deprescribing practices and influencing best practices in health care.
BACKGROUND: ClinicalTrials.gov NCT06110975; https://clinicaltrials.gov/study/NCT06110975.
UNASSIGNED: DERR1-10.2196/56277.

BACKGROUND: General 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.
METHODS: A 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.
RESULTS: The 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.
CONCLUSIONS: The 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.

OBJECTIVE: The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults.
METHODS: 11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2).
RESULTS: We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment.
CONCLUSIONS: Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups.
BACKGROUND: PROSPERO CRD42020178860.

暂无摘要。

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.
CONCLUSIONS: 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.
BACKGROUND: The study is registered at ClinicalTrials.gov (identifier: NCT05507177).