Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults Too much medicine is an increasingly recognised problem, 1 2 and one manifestation is inappropriate polypharmacy in older people. Polypharmacy is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms) 4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission. [5][6][7] There is limited evidence to inform polypharmacy in older people, especially those with multimorbidity, cognitive impairment, or frailty.8 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life. [9][10][11] Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.12 13 Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing. 15 However, shared decision making in this context is not easy, and there is little guidance on how to do it. 16 We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians (figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table). 17 18 Process for deprescribing with older adultsStep 1: creating awareness that options existThe clinician and patient acknowledge that a decision can be made about continuation or discontinuation of medicines, and that this requires input from both clinician and patient. When to initiate discussions about deprescribingPrescribing new medicines is often straightforward, driven by a new diagnosis, symptom, or test result. When to consider ceasing medicines is less clear.12 Possible triggers include the number of medicines taken (perhaps ≥10); a new symptom that may be an adverse effect of a medicine; identifying high risk, ineffective, or unnecessary medicines; apparent non-adherence; or changed treatment priorities. 19 Most of these situations can be identified only by a medicines review. Reviews can be triggered by important life transitions (such as hospital admission, a new diagnosis, or seeing a new doctor) and can be initiated by the clinician or patient, but they are often Older people's attitudes towards medicineClinicians may be reluctant to initiate discussions about deprescribing with older people, believing tha...

Objective: Health technology financing is often based on randomized controlled trials (RCTs), which are often the same ones used for licensing. Since they are designed to show the best possible results with typically Phase III studies conducted under ideal and highly controlled conditions to seek high internal validity and maximize the chance of demonstrating clinical benefit, they often do not reflect likely effectiveness in routine clinical care. Consequently, it is not surprising that technologies do not always perform in real life in the same way as controlled conditions. Since financing (and price paid) decisions can be made with overestimated results, health authorities need to ask whether health systems achieve the results they expect when they choose to pay for a technology. The optimal way to answer this question is to assess the performance of financed technologies in real world settings. Health technology performance assessment (HTpA) refers to the systematic evaluation of the properties, effects, and/or impact of a health intervention or health technology in the real world to provide information for investment/ disinvestment decisions and clinical guideline updates. The objective is to describe the development and principal aspects of the Guideline for HTpA commissioned by the Brazilian Ministry of Health. Method: Extensive literature review, refinement with experts across countries and public consultation. Results: A comprehensive guideline was developed, which has been adopted by the Brazilian government. Conclusion: We believe the guideline, with its particular focus on disinvestment, along with the creation of a specific program for HTpA, will allow the institutionalization and continuous improvement of the scientific methods to use real world evidence to optimize available resources not only in Brazil but across countries.Keywords: Technology Assessment, Biomedical; Observational studies; Health policy; Health Information Systems Policy implications: Real-world evidence is emerging as an important tool to aid decision-making regarding health technology financing. Over the last decade, countries have developed health and/ or administrative registries capable of providing quality data for assessing health results in real life. At the same time, budgetary constraints and the pressure to finance emerging high-priced technologies are making it inevitable for health authorities to start assessing whether patients and society are getting the results from financed technologies agreed upon during investment decisions. This paper presents the concept of Health Technology performance Assessment and the development of a guideline, commissioned by the Brazilian Ministry of Health, to implement such activity. We believe it is the first guideline to formally incorporate the use of real-world evidence for updating clinical guidelines, price renegotiation and disinvestment decisions.

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ObjectiveNPS MedicineWise aims to ensure that medicines are prescribed and used in a manner consistent with current evidence-based best practice. A series of nationwide educational and advertising interventions for general practitioners and consumers were implemented in Australia between 2009 and 2015 with the aim of reducing antibiotic prescriptions for upper respiratory tract infections (URTIs). The work described in this paper quantifies the change in antibiotic dispensing following these interventions.MethodsAntibiotic dispensing data between 2004 and 2015 were obtained from a national claims database. A Bayesian structural time series model was used to forecast a series of antibiotic dispensing volumes expected to have occurred if the interventions had not taken place. These were compared with the volumes that were actually observed to estimate the intervention effect.ResultsOn average, 126,536 fewer antibiotics were dispensed each month since the intervention programs began in 2009 (95% Bayesian credible interval = 71,580–181,490). This change represents a 14% total reduction in dispensed scripts after the series of intervention programs began in 2009.ConclusionsContinual educational intervention programs that emphasise the judicious use of antibiotics may effectively reduce inappropriate prescribing of antibiotics for the treatment of URTIs at a national level.

Objective The Brazilian National Health System provides high cost medicines through the Specialized Component of Pharmaceutical Assistance in accordance with the adherence to agreed Clinical Guidelines. However, physician compliance to these Guidelines, as well as the barriers and facilitators related to them and the influence on the subsequent quality of care provided is unknown. Consequently, the objectives of this article are to undertake a review of international experiences and scientific publications of a strategy to disseminate and communicate guidelines to physicians through Academic Detailing. Subsequently, use the findings to develop and conduct a pilot Academic Detailing Programme in Brazil targeting specialists who prescribe medicines for patients with Alzheimer's disease, which are part of the Specialized Component of Pharmaceutical Assistance. Methods Review international experiences and scientific publications relating to academic detailing based on a thorough review of available literature including publications known to the coauthors. Develop and monitor physician acceptance of academic detailing for patients with Alzheimer's disease and the impact on future prescribing. Key findings Based on the lessons learnt from the international experience and review, coupled with the initial experiences in Brazil, we conclude that conducting academic detailing to enhance the implementation and dissemination of clinical protocols and therapeutic guidelines in Brazil is worthwhile. We will be closely monitoring the outcome of the pilot academic detailing programme as a basis for developing future programmes to further improve the quality of prescribing in Brazil. Conclusions Findings from the experiences are encouraging. This will be further explored to provide a basis for this approach in the future.