Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

Proton pump inhibitor use and risk for recurrent Clostridioides difficile infection: a systematic review and meta-analysis

ObjectivesProton pump inhibitor (PPI) therapy is a potentially modifiable risk factor for recurrent Clostridioides difficile infection (CDI). Citing an absence of clinical trials, many guidelines do not provide recommendations for addressing PPI management. Our aim was to perform an updated systematic review and meta-analysis evaluating the association between PPI use and recurrent CDI addressing prior methodological limitations.MethodsData sources were MEDLINE and EMBASE. Eligible studies were cohort and case–control studies; there were no restrictions on study setting or duration of follow-up. Participants were adults with prior CDI who did or did not receive PPI therapy and were assessed for recurrent CDI. Summary (unadjusted) odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Prespecified subgroup analyses were performed to explore heterogeneity including study design, study quality, duration of follow-up, adjustment for confounders, and outcome definition.ResultsSixteen studies were included in the meta-analysis, comprising 57 477 patients with CDI, of whom 6870 (12%) received PPIs. The rate of recurrent CDI was 24% in patients treated with PPIs versus 18% in those who were not. A meta-analysis that pooled unadjusted odds ratios demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.69, 95%CI 1.46–1.96) versus those who did not. There was moderate heterogeneity between studies (I² 56%); however, a sensitivity analysis restricted to studies with 56 days of follow-up substantially reduced the heterogeneity (OR 1.59, 95%CI 1.36–1.85; I² 12%). An analysis restricted to multivariate studies that combined adjusted ORs also demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.49, 95%CI 1.12–2.00). No publication bias was identified.ConclusionsWe found significantly higher odds of recurrent CDI among users of PPIs that persisted across multiple sensitivity analyses. These results support stronger recommendations for PPI stewardship at CDI diagnosis.     

Implementing deprescribing guidelines into frontline practice: Barriers and facilitators

A Bruyère Evidence-Based Deprescribing Guideline Symposium was held in March 2018; one component focused on implementing deprescribing guidelines into practice. An interactive discussion activity allowed the 107 participants to share experiences and ideas concerning the barriers and facilitators that arise when moving deprescribing guidelines into frontline practice. Participants identified 8 broad challenges and problem areas. These included challenges and barriers that arise in the daily practices of pharmacists and prescribers and in other health care settings, and those related to existing policies, processes, and financial structures. They also identified 10 factors that facilitated implementation efforts, including: educating patients, caregivers, health care providers (HCPs) and staff; improving collaboration across practice disciplines; expanding the evidence for deprescribing; and fostering organizational cultures of deprescribing. The results indicate that participants are committed to deprescribing and are moving forward with efforts to bring about change. Participants recognize that the implementation of deprescribing is best conceived of as a comprehensive systems change, and that patients and the public need to be involved in deprescribing processes and activities.     

Deprescribing: Future directions for research

A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies.     

Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review

BackgroundPolypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review.ObjectiveThis scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW).MethodsA scoping review was conducted that involved searches of six databases (2002–2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT).ResultsSearches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion.ConclusionsDeprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.     

Deprescribing opportunities for elderly inpatients in an academic,safety-net health system

BackgroundDeprescribing is one way to reduce inappropriate polypharmacy in older adult patients. Although algorithms have been published to guide practitioners in deprescribing, it is still unknown how applicable these algorithms are to the general older adult population.ObjectivesThe primary objective was to assess the applicability of published deprescribing protocols in hospitalized older adult patients.MethodsThis retrospective study included patients aged 65 years or greater who were discharged from an internal medicine team between January 1, 2017 and June 30, 2017. Along with age and admission to internal medicine wards, other eligibility criteria were extracted from published deprescribing protocols. The primary endpoint was the proportion of patients eligible for deprescribing based on published algorithms. Secondary endpoints included the proportion of patients receiving medications which were included in an algorithm, proportion of patients using medications included in the algorithms who were eligible for deprescribing, and proportion of patients with medications deprescribed during the hospital stay.ResultsTwo hundred sixty-seven patients were included and 124 (46.4%) used a medication with a published deprescribing algorithm. Thirty-four percent of all patients and 74% (92/124) of patients prescribed medications included in algorithms were eligible for deprescribing. Seven percent (6/92) of patients eligible for deprescribing had medications deprescribed during the hospital stay.ConclusionThe application of deprescribing algorithms in hospitalized older adults identified a significant opportunity to initiate deprescribing practices.