Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial

Abstract

Objectives: Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate. Design: Pragmatic multicenter stepped-wedge cluster randomized controlled trial. Setting and Participants: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications. Methods: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months. Results: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P ¼ .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately threequarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians. Conclusions and Implications: Multidisciplinary medication reviewedirected deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine.Polypharmacy, or the concurrent use of multiple medications, is common among nursing home residents, which heightened the risk of using potentially inappropriate medication (PIM). 1 A recent systematic review found that about half of older nursing home residents were exposed to PIM, which can lead to greater incidences of adverse events. 2 Adverse outcomes such as fall risks 3 and falls 4 were associated with the use of polypharmacy, particularly when fall The authors declare no conflicts of interest.

Pharmacist‐led intervention on chronic pain management: A systematic review and meta‐analysis

“…Suboptimal use of analgesics, inappropriate use of repeat prescriptions, and self‐medication with over‐the‐counter drugs together with prescribed analgesics, non‐adherence and adverse drug effects are some of the common issues that need a medication review 31 . The value of pharmacists in conducting medication reviews has been well established to optimize drug therapy and reduce drug‐related problems 30,32–34 . Pharmacist‐implemented pharmaceutical care plans 15,18,20 or use of educational videos 27 are some of the additional interventions to medication review that have been noted in this review.…”

Medications in Post-Acute and Long-Term Care: Challenges and Controversies

“…Deprescribing typically follows a formal medication review protocol, which is informed by one or more of the tools that are now available to help clinicians identify medications to target for reductiondmost notably the AGS Beers criteria and the STOPP/START Criteria. 57e59 This issue of JAMDA reports results from 2 deprescribing programs: a randomized trial in 4 Singapore nursing homes, which demonstrated reductions in pill burden, costs, hospitalizations, and mortality 60 ; and a preliminary report from Australia of an electronic system in an acute hospital that focused on deprescribing and was shown to lower overall drug burden and potentially inappropriate medications. 61 These and other studies indicate that although purists would advocate that "right prescribing" is the ultimate goal, deprescribing has gained a legitimate and useful role in medication management in post-acute and long-term care.…”

Deprescribing Statins and Proton Pump Inhibitors in Nursing Home Residents; a Pragmatic Exploratory Study

“…A possible solution for reducing inappropriate polypharmacy is called "deprescribing": a planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit (Scott et al, 2015). Kua et al (2021) determined the effect of a deprescribing intervention by means of a stepped-wedge cluster-randomized controlled trial and showed that deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes (Kua et al, 2021).…”

“… Kua et al (2021) determined the effect of a deprescribing intervention by means of a stepped-wedge cluster-randomized controlled trial and showed that deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes ( Kua et al, 2021 ).…”