Emily Reeve

Patient barriers to and enablers of deprescribing: a systematic review.

BackgroundInappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process.ObjectivesThe aim of this study was to identify barriers and enablers that may influence a patient’s decision to cease a medication.Data sourcesA systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers’ beliefs were utilised.Study eligibility criteriaArticles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased.Study appraisal and synthesis methodsDetermination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results.ResultsTwenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with ‘appropriateness’ of cessation, absence/presence of a ‘process’ for cessation, and negative/positive ‘influences’ to cease medication, were identified as both potential barriers and enablers, with ‘fear’ of cessation and ‘dislike’ of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was ‘appropriateness’ of cessation, with 15 studies identifying this as a barrier and 18 as an enabler.Conclusions and implications of key findingsThe decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.

People's Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe

To capture peoples attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications.

Benefits of deprescribing on patients' adherence to medications

Deprescribing is a holistic process of medication cessation that encompasses gaining a comprehensive medication list, identifying potentially inappropriate medications, deciding if the identified medication can be ceased, planning the withdrawal regimen and monitoring, support and follow-up. It is currently being investigated as a mechanism to reduce unnecessary or redundant medications. However, given the systematic and patient-centred nature of the deprescribing process, it is possible that it may also confer additional benefits such as improving adherence to medications, even if there is no net reduction in overall medication use. Specifically, deprescribing may improve adherence via reducing polypharmacy, reducing the financial costs associated with medication taking, increasing the patient’s medication knowledge through education, increasing patient engagement in medication management and resolution of adverse drug reactions. More research into deprescribing must be conducted to establish if these potential benefits can be realised, in addition to establishing any negative consequences.

Feasibility of a Patient-Centered Deprescribing Process to Reduce Inappropriate Use of Proton Pump Inhibitors

Background: Proton pump inhibitors (PPIs) are inappropriately prescribed in up to 50% of users. Systematic medication review and cessation of inappropriate medications or deprescribing may improve patient outcomes and reduce costs. Objective: The aim of this study was to assess the feasibility of a patient-centered deprescribing process in a population of adults with complex polypharmacy. Methods: This was a prospective feasibility study. Participants were recruited from hospital outpatient clinics. The patient-centered deprescribing process consisted of 5 steps: comprehensive medication history, identification of potentially inappropriate medications, determining if the medication can be ceased, planning the withdrawal regimen (eg, tapering where necessary), and provision of monitoring, support, and documentation. Feasibility was determined by assessing time taken to complete the different steps of the deprescribing process and participant feedback. Results: In all, 57 PPI users were recruited; participants were 70 ± 14 years old and took 14 ± 6 medications. The indication for PPI use was verified in 43 participants and judged as potentially inappropriate in 19 (44%); 8 were suitable for trial withdrawal, and 6 consented. All 6 successfully ceased (n = 3) or reduced (n = 3) their PPI use, and this was sustained at 6 months postintervention in 4 participants. Conclusions: The patient-centered deprescribing process can safely reduce inappropriate PPI prescribing in a small proportion of people. Although the process was acceptable to participants, difficulties in accessing complete medical histories, time limitations, and minimal evidence to support effectiveness in certain indications were barriers to implementation of the process in clinical practice.

Enhancing Continuing Education Activities Using Audience Response Systems: A Single‐Blind Controlled Trial

Introduction: We investigated whether using an audience response system (ARS) as part of continuing education (CE) activities enhances immediate and long‐term knowledge acquisition or learner reactions. Method: A multicenter single‐blinded controlled trial involving pharmacists at 2 metropolitan teaching hospitals was used for this investigation. Pharmacists were allocated to either (a) an interactive presentation incorporating multiple‐choice questions (MCQs) answered using an ARS, or (b) the same, but noninteractive, presentation using summary points instead of MCQs. Baseline knowledge was evaluated using a 10‐item questionnaire, which was also used to evaluate immediate and long‐term (6 weeks later) knowledge acquisition. Learner reactions were evaluated through feedback questionnaires. Results: The control and ARS intervention presentations were attended by 44 and 35 pharmacists, respectively. The 6‐week follow‐up questionnaire was completed by 35 control (80%) and 27 (77%) ARS group participants. Baseline knowledge was similar across groups (5.0 ± 1.6 SD vs 5.2 ± 1.6; p = .44) with no differences in immediate (8.3 ± 1.5 vs 7.9 ± 1.5; p = 0.30) or long‐term (7.0 ± 1.6 vs 7.0 ± 1.5; p = 0.93) knowledge acquisition. Feedback regarding the use of an ARS was overwhelmingly positive, with participants feeling more strongly that the ARS enabled them to compare knowledge to that of their peers (p < .001). Discussion: There was no observed benefit of an ARS in relation to immediate or long‐term knowledge acquisition. The use of an ARS, however, appeared to facilitate enhanced interactivity and participant self‐reflection of knowledge, with strong participant desire to continue their use in future CE activities.

Enhancing Education Activities for Health Care Trainees and Professionals Using Audience Response Systems: A Systematic Review.

Introduction: This review examines the effect of incorporating clickers within practice-based education sessions on educational outcomes of health care trainees and professionals. Methods: A systematic literature review was conducted on primary research studies published up until August 2014. Studies were identified by database searching (Ovid MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and PsychInfo), citation searching, and reference list checking. Studies were restricted to those evaluating the use of clickers as part of the provision of postgraduate education or continuing education programs and were evaluated according to Kirkpatricks four levels of training evaluation (reaction, learning, behavior, and results). Results: Seventeen studies met the eligibility criteria. Twelve studies assessed learner and/or speaker reactions, with feedback overwhelmingly positive in all studies. Reported learner benefits included increased attentiveness, engagement, and enjoyment of presentations. Speakers reported that using clickers engaged the audience and assisted in assessing audience comprehension. Eight studies assessed learning outcomes. Higher level evidence obtained from four randomized studies demonstrated significant improvements in knowledge with the use of clickers compared with traditional didactic presentations, but no differences when clickers were compared with an interactive lecture with integrated questions. No studies adequately assessed higher level educational outcomes (behavior and results). Conclusion: Although the use of clickers improves learning environment and learner satisfaction, the limited high-quality data for improvements in learning and behavior outcomes make it uncertain whether the acceptance and implementation of clickers within routine practice-based education programs are warranted at this stage.

Patients' perspectives on the brave new word ‘deprescribing’

wherethedifficultyinsearchingforresearchregarding cessation of medications due to the lackof a standardized term for it was highlighted. Whiledeprescribing has been defined as medication cessation, theterm is broader than simply cessation and encompasses theprocess of trial medication withdrawal. Deprescribing mayinclude gaining a complete medication history, identifyingmedications for withdrawal, medication tapering and moni-toring following cessation.

Difficulties Reducing Inappropriate Prescribing of Proton Pump Inhibitors in the Elderly

We congratulate Hamzat et al. [1] on their work, which demonstrated the efficacy of an educational strategy to reduce inappropriate proton pump inhibitor (PPI) prescribing in elderly inpatients. The discussion provided a good picture of the issues surrounding PPI use, and we were particularly pleased to see that this study was conducted in the elderly (age [65 years), as this group is renowned as a group that is under studied, despite being the most likely population to suffer ill-effects from PPIs [2, 3], and therefore the most likely to benefit from any such intervention to reduce PPI use. The authors report about a 45 % success of cessation or dose reduction of inappropriate PPIs in the intervention and post-intervention period. Whilst this result is positive, the authors did not elaborate on why the remaining half of PPI use that was judged to be inappropriate was not ceased; we propose several possibilities. This level of success may be all that is achievable with an educational strategy. As a tool to reduce inappropriate prescribing, educational interventions have mixed effects [4], and as mentioned by the authors, a previous educational intervention to reduce PPI use was not effective [5]. As Hamzat et al. [1] describe a purely educational intervention, the assessment of PPI appropriateness performed by the investigators was not provided to the attending doctor. Therefore, the success of this intervention relied on the individual doctors to assess appropriateness and initiate ‘deprescribing.’ This means that time limitations, knowledge and previous experience, all of which may be subject to ‘seasonal’ variation, may have influenced the number of PPIs that were identified as inappropriate and the number that were deprescribed. There was limited detail provided in this article on the assessment of PPI appropriateness in terms of both how the information related to PPI use was gathered and the criteria used to determine appropriateness. While the authors report that a comprehensive medication review was conducted on admission, the sources of information were only the general practitioner list and hospital records, which are known to contain inaccuracies in relation to what medications the patient is actually taking [6]. There was no discussion on the information that is required to be able to determine appropriateness, and we propose that a PPI cannot confidently be identified as being inappropriately used without speaking to the patient themselves, as they are the only ones who are able to provide information on their current symptoms and adherence to the prescribed treatment. In many cases, it is also essential to know the results of endoscopies, or in fact if an endoscopy has ever been performed. Appropriate PPI indications in this article were derived from the British National Formulary and NICE guidelines, which, on the whole, provide a list of very clear appropriate (and inappropriate) indications; however, there are some indications where appropriateness is not so clear, particularly in the elderly. For example, in the primary prevention of peptic ulcer disease in low-dose aspirin users, PPIs have been shown to be effective, but it has not been established if there is sufficient benefit versus risk with regard to using PPIs over cheaper alternatives such as histamine H2 receptor antagonists. E. Reeve (&) M. D. Wiese School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia e-mail: emily.reeve@mymail.unisa.edu.au