Pharmacist-Led Intervention Improves Deprescribing

Marcia Frellick

November 13, 2018

A two-part pharmacist-led intervention was associated with a dramatic reduction in the number of older adults in Quebec, Canada, who filled inappropriate prescriptions, a study has found.

In a cluster randomized trial of 489 adults 65 years and older recruited from 96 community pharmacies, the percentage of participants who had stopped taking targeted inappropriate prescriptions at 6 months was 43% in the intervention group, significantly higher than the 12% who received usual care (risk difference, 31%; 95% CI, 23% - 38%).

The findings were published today in the JAMA.

Researchers compared two randomized groups: 248 patients in the D-PRESCRIBE intervention group (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly) and 241 patients in the control group, who received usual care.

In the intervention group, community pharmacists were encouraged to give brochures to patients, either in person or by email, describing why certain medications may be inappropriate as well as suggesting alternatives and strategies for stopping the drugs. At the same time, pharmacists conveyed their evidence-based opinion on a template given to the patient's physician, a reimbursed service in Quebec. Those in the usual care group did not receive educational materials.

Patients, physicians, pharmacists, and evaluators were blinded to outcome assessment.

The trial included adults who were prescribed one of these potentially inappropriate medications: sedative-hypnotic drugs, nonsteroidal anti-inflammatory drugs, glyburide, or first-generation antihistamines.

There were no adverse events that required a hospital stay, but 29 of the 77 patients who tried to taper their use of sedative-hypnotic drugs reported withdrawal symptoms, according to the article. However, the authors note, they didn't collect information on adverse events beyond those that required hospitalization or those that patients experienced with sedative-hypnotic withdrawal.

Many Reasons Inappropriate Prescribing Persists

High rates of inappropriate use of the targeted drugs persist among older adults in outpatient settings and can lead to adverse events, including cognitive impairment, falls, and hospitalizations.

"It has been estimated that 29.0% of Medicare beneficiaries aged 65 years and older in the United States in 2015 and 31.1% of older adults in Canada in 2016 filled a prescription for at least one medication included in the 2015 American Geriatrics Society Beers Criteria list of drugs to avoid in older adults," the authors write.

Barriers to stopping the use of these drugs include prescribers' lack of time, poor awareness of the harms, and fear that stopping the drugs will cause withdrawal symptoms.

Michael A. Steinman, MD, with the Division of Geriatrics at the University of California San Francisco and San Francisco Veterans Affairs Health Care System, and C. Seth Landefeld, MD, with the Department of Medicine at the University of Alabama at Birmingham, write in an accompanying editorial that the study teaches two key lessons.

One lesson is an effort that includes patients, physicians, and pharmacists is likely to help overcome the inertia inherent in long-term medication use. Prior efforts that have tried to motivate only one of these groups to make a change have often failed, they note.

The second lesson is the key role of pharmacists, who are often overlooked in leadership for quality-improvement initiatives, they write.

"Pharmacists can initiate and catalyze deprescribing by providing the expertise, focus, and targeted recommendations that can guide physicians while serving as trusted arbiters and sources of advice for patients, including for issues that some patients may be reluctant to tell their physician," Steinman and Landefeld write.

Patients in the study were recruited from February 2014 to September 2017, with follow-up until February 2018. The mean age of patients was 75 years and 66% were women.

Eligible pharmacies had patient populations that included at least 20% of adults 65 years and older. Eligible patients were older adults who had filled a prescription for one of the targeted drugs for at least 3 consecutive months before screening for the trial.

The study was funded by Canadian Institutes of Health Research. Martin has reported receiving support from the Michel Saucier Endowed Chair in Pharmacology, Health and Aging, Faculty of Pharmacy, University of Montreal. Two coauthors are clinician-scientists funded by the Fonds de Recherche en Santé de Quebec. The editorialists have declared no relevant financial relationships.

JAMA. 2018;320:1889-1898, 1867-1869.

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