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This article is shared from the NIHR Evidence website – review this and more articles, and subscribe to alters at https://evidence.nihr.ac.uk/.
A review including 28 papers suggested ways to improve deprescribing in primary care.
They include:
- clearly defined roles and responsibilities, with good communication between multidisciplinary team members, and pharmacists integrated within teams
- targeted training and education
- routine discussions about deprescribing when prescribing, with medication reviews tailored to patients’ needs and preferences
- involvement of patients and informal carers, and trusted relationships with professionals allowing continuity of care.
The researchers hope their findings will help make deprescribing more efficient.
More information about polypharmacy can be found on the NHS website.
The issue: how to reduce polypharmacy in everyday practice
1 in 3 people aged 65 and older take 5 or more medicines every day (polypharmacy). Some of these drugs may no longer be appropriate. They could increase the risk of falls, hospital admission, or even death, especially among people who are frail (and less able to recover from injury and illness).
Deprescribing (reducing, stopping or switching drugs) is safe for some conditions, medications and in settings such as primary care. Advice is available, for instance from the Kings Fund and Health Improvement Scotland, to help clinicians deprescribe during medication reviews. But clinicians face time constraints and may, for example, be concerned about stopping medication which was first prescribed by a specialist.
Previous research highlights the role of the multidisciplinary team in medication reviews, and suggests that pharmacists have the specialist knowledge and skills to lead reviews. The team reviewed studies on older people in primary care to explore when and why deprescribing takes place and how best to involve the multidisciplinary team.
“This work has identified key mechanisms for a successful multidisciplinary team approach to deprescribing in primary care. If implemented, it could lead to a significant change in patient care and safety.
Key elements include a supportive infrastructure that facilitates pharmacists taking a lead role within a well-integrated and co-located team. Also, clear roles, good communication and collaboration, that draws on the strengths and expertise of multidisciplinary team members. Patients and carers need to be involved and engaged in the process.
Future research should focus on developing deprescribing interventions to improve team working and communication. They could apply learning from the way multidisciplinary teams work in other specialties such as surgery and oncology, within the primary care working environment.”
Kinda Ibrahim, Associate Professor, Faculty of Medicine, University of Southampton
What’s new?
The researchers analysed 28 papers (including 10 randomised controlled trials) involving people aged 65 years and older who lived at home (not in hospital or care home). Studies were published between 2003 and 2023; most were from the Netherlands, USA, Canada and New Zealand. The team developed and refined suggestions with the help of 26 primary care clinicians, 10 patients and 3 informal carers. They identified 4 conditions for successful deprescribing.
- Clearly-defined roles
For instance, pharmacists leading medication reviews, with GPs making the final decision, drawing on the expertise of other professionals such as nurses, social prescribers and frailty practitioners. Plus supportive infrastructure, good relationships, communication and collaboration (including between primary and secondary care). - Training and education
Many clinicians are concerned about stopping treatments safely; guidance on deprescribing is lacking. Clinicians benefit from training on prescribing and deprescribing throughout their career. Effective education includes team discussion and shared decision-making with patients and carers. - Routine discussions about deprescribing
Deprescribing is most effective when:- it is discussed with patients at the time medication is started
- tools help identify people who might benefit
- team members work in the same place and can all access patient records
- medication reviews are convenient and safe, ideally in-person for people living with frailty or dementia (for some with less complex needs, reviews may be done by phone)
- discussions include safety-netting advice and tailored monitoring plans so that patients know when to seek help.
- Patient and carer involvement
Patients and carers who trust their clinicians are more likely to accept deprescribing. They need to know why a drug might be stopped or reduced; deprescribing framed as a pause in treatment (that could be restarted) can increase their confidence. Informing patients and their carers about discussions with their specialists could reassure those whose medication was started in secondary care.
Why is this important?
The researchers hope their findings will help people understand what good deprescribing looks like and inform the design of interventions and services that embed deprescribing in primary care. Their suggestions, which emphasise the multidisciplinary approach, could inform future deprescribing interventions for primary care.
These findings build on previous research covered in an NIHR Evidence summary. The suggestions could make deprescribing more efficient, which could help time-pressed GPs. Reviews conducted by other prescribers within the team (such as pharmacists) could also help, as could coinciding reviews with other appointments at the practice.
The researchers suggest that pharmacists are well-placed to lead medication reviews. The researchers note that their study drew upon findings from countries where pharmacists do not prescribe and were not usually part of the primary care team. The role of pharmacists in the UK has evolved; recent evidence suggests that integrating pharmacists into primary care reduces both GP appointments and emergency department attendance, but increases overall use of primary care.
“Our realist review has shown the importance of a patient-centred approach in the deprescribing process, and developing a trusting relationship between patients and health care professionals. Future research needs to focus on how best this can be facilitated, not only through patient information and education, but also through developing approaches that enable health care professionals to actively involve both patients and carers in prescribing and deprescribing discussions, and agree tailored follow-up plans that allow continuity of care.”
Eloise Radcliffe, Senior Research Fellow, Faculty of Medicine, University of Southampton
What’s next?
This realist review is part of a larger project that aims to develop a multidisciplinary deprescribing intervention in primary care for older people (the MODIFY study). This is being tested in Wessex GP practices.
Deprescribing needs to become a routine part of prescribing, discussed with a patient when a medication is first prescribed. Agreeing on treatment goals from the outset can guide future conversations about medications.
Pharmacists have a central role in deprescribing, but other primary care clinicians, including nurse practitioners and social prescribers, could be involved.
Training is needed. Other research teams are developing a deprescribing course for pharmacists, and guidance for nurses working in general practice.
You may be interested to read
This is a summary of: Radcliffe E, and others. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatrics 2023; 23: 591.
Information about managing polypharmacy from the Royal Pharmaceutical Society.
Pereira A, Verissimo M. Deprescribing in older adults: time has come. European Geriatric Medicine 2022; 14: 1 – 3.
An NHS tool about deprescribing.
Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. National Institute for Care Excellence Guideline 5, March 2015.
A course about polypharmacy and deprescribing for primary care clinicians.
An NIHR Evidence summary about helping GPs to deprescribe medications for people with multiple long-term conditions.
Funding: This study was funded by the NIHR ARC Wessex.
Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the original paper.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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