Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial

Abstract

Background Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients. Methods This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures. Results Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures. Conclusion Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success. Trial registration Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014. The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

An Update on Medication Use in Older Adults: a Narrative Review

“…It has undergone pilot testing in community pharmacies in Northern Ireland and England; whilst study procedures and intervention delivery were reported to be feasible, the authors plan to make modifications before progressing to a cluster RCT to explore intervention effectiveness [92]. Other approaches that have been utilised in interventions to support prescribing and medication use in older people include electronic clinical decision support systems [94,95] and deprescribing [96,97]. Whilst deprescribing interventions may reduce mortality and the use of potentially inappropriate medications, and improve medication adherence [96,98,99], the effect may not be sustained, and further research is needed to determine the optimal interval of repeated deprescribing interventions [97].…”

“…Other approaches that have been utilised in interventions to support prescribing and medication use in older people include electronic clinical decision support systems [94,95] and deprescribing [96,97]. Whilst deprescribing interventions may reduce mortality and the use of potentially inappropriate medications, and improve medication adherence [96,98,99], the effect may not be sustained, and further research is needed to determine the optimal interval of repeated deprescribing interventions [97]. A multi-faceted intervention for primary care has been proposed that includes an adapted versio n of a deprescribing protocol which may reverse prescribing cascades [100].…”

A narrative review of evidence to guide deprescribing among older adults

“…For instance, short‐term indirect effects include contamination bias associated with intervention implementation. In a cluster RCT in Switzerland 99 and a pre‐ and postintervention study in Japan, 100 deprescribing interventions were associated with a decrease in the number of medications used in the usual care group. It is possible that the implementation of polypharmacy interventions may have a desirable impact on culture and usual care at their institutions.…”

“…‐Patient‐centered deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months 99 …”

Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis

“…However, it may also be that physicians try not to prescribe complex treatments to physically and/or cognitively dependent older adults at their discharge, as they would probably struggle to manage them during this specific period. Therefore, our results may indicate growing concerns about prescriptive practices in Switzerland [ 54 ].…”