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Table 1 Characteristics of included studies

From: Evidence for deprescription in primary care through an umbrella review

Review

Objective

Methodology

Results

Conclusion

Effectiveness of interventions for the deprescription

 Page (2016) [17]

Determine whether prescription is a safe, effective and feasible intervention for improving mortality and health outcomes amongst the elderly.

Specific database searches of articles published up to February 2015. A qualitative and quantitative summary of the information was made.

A total of 132 articles were included (n = 34,143). Observational studies showed that polypharmacy significantly reduced mortality (OR 0.32; 95% CI: 0.17–0.60), but randomized studies did not (OR 0.82; 95% CI 0.61–1.11). Deprescription showed a significant decrease in mortality (OR 0.62; CI 95%: 0.43–0.88) in interventions tailored to patients but not in generalized educational programme (OR 1.21; 95% CI: 0.86–1.69).

Although observational studies suggested that deprescription reduces mortality, this was not observed in randomized studies. When tailored interventions were used, mortality was significantly reduced.

 Reeve (2017) [18]

Assess the interventions used to reduce benzodiazepines and Z-drugs, and the impact of these interventions on clinical outcomes in the elderly population.

Database searches for studies carried out with older adults (> 65 years old) between 1995 and 2015. A qualitative and quantitative summary of the information was made.

Seven studies were included. Substitution with melatonin achieved a deprescription rate of 64.3%, with this being 65% in the case of interventions directed by physicians. Interventions which included education and dose reduction (n = 2), pharmacological substitution with psychological support (n = 1) and dose reduction with psychological support (n = 1) showed rates ranging from 27 to 80%.

The deprescription of benzodiazepines is feasible amongst the elderly population, but these rates vary according to the type of intervention. Further studies must be carried out to assess the effectiveness of these interventions.

 Hansen (2018) [19]

Evaluate the effectiveness of behaviour change techniques (BCTs) in deprescription interventions

Database searches for studies carried out with older adults (> 65 years old) up to December 2016.

25 studies were included. The number of medications at follow-up was significantly reduced (mean difference − 0.96 95% CI − 1.53, − 0.38; p < 0.002). No effects were shown according to intervention type (patient-centred or targeting solely healthcare professionals) or study quality.

BCT deprescription interventions were effective in reducing number of drugs and inappropriate prescribing, but a large heterogeneity in effects was observed.

 Dills (2018) [20]

Evaluate the outcome of deprescription compared with standard care.

Database searches for randomized controlled trials involving chronic medical and mental health conditions managed by PCPs

A total of 58 articles were included, two of them were classified as educational interventions (modest deprescription was achieved, without any increase in measured adverse outcomes), twelve were patient drug specific interventions, and six were mixed interventions (educational component plus patient drug-specific interventions, 4 of the 6 studies were successful).

Interventions with the most success in reducing polypharmacy included intense a pharmacist intervention, providing both clinician education as well as patient-specific drug recommendations

 Wilsdon (2017) [21]

Determine the effectiveness of interventions for the deprescription of inappropriate proton pump inhibitors amongst the elderly.

Database searches for studies carried out with older adults (> 65 years old) up to January 2017.

21 studies were included. Effective interventions included educating a wide sector of the population and a promotion strategy, providing academic information to GPs, and geriatrician-led prescription for institutionalised patients.

Limited evidence shows that some interventions are more effective than others. There is no evidence that deprescription leads to improved clinical outcomes.

Barriers and enablers of the deprescription

 Sirdifield (2013) [22]

Review qualitative studies which explore the experiences and perceptions of physicians about the prescription of benzodiazepines, in order to construct a model explaining the processes underlying current prescription practices.

A search of 7 databases between 1990 and 2011. Results were summarised according to topic.

8 articles were included. Given the limitations of general daily practice prescribing benzodiazepines is complex, awkward and demanding. Physicians face different challenges when initiating, continuing or withdrawing treatment with these drugs.

Results can be used to improve the prescription of benzodiazepines by educating medical professionals about their use and withdrawal, and by improving communication with patients.

 Anderson (2014) [23]

Summarise qualitative studies exploring barriers perceived by prescribers, and enablers for minimising the prescription of potentially inappropriate medicines (PIM) to adults.

Searches in specific databases up to March 2014. A qualitative and quantitative summary of the information was made.

21 studies were included (85.7% in primary care). Barriers and enablers for minimising PIM could be grouped into 4 areas: awareness of the problem; secondary inertia, with more inclination to continue rather than cease PIM; self-efficacy as relating to one’s ability to change prescriptions; and the viability of changing prescriptions in patient care environments.

Multiple interdependent factors shape the behaviour of prescribers with regards to continuing or discontinuing a prescription of PIM. Full understanding of barriers and enablers is required in order to develop interventions aimed at reducing PIM consumption and the risk of iatrogenic harm.

 Reeve (2013) [24]

Identify barriers and enablers which have an influence on patient decision to stop taking a given medicine.

Database searches for studies carried out with older adults (> 65 years old) up to August 2011.

21 studies were included (1310 participants). 3 areas: agreement with the appropriateness of ceasing medication, lack of a process for ceasing medication, and ‘influences’ on medication cessation. Amongst the barriers and enablers identified was fear of ceasing medication, with the most commonly identified barrier being the appropriateness of ceasing medication.

The decision to cease a given medication is influenced by multifactorial variables. The most common barrier/enabler identified was appropriateness of cessation.

 Sirdifield (2017) [25]

Identify and summarise qualitative studies which explore the experiences and perceptions of patients being prescribed benzodiazepines and Z-drugs and, in this way, identify factors which perpetuate the use of these drugs and strategies for achieving safer prescription.

A systematic search in 6 databases for qualitative studies was conducted between January 2000 and April 2014. Results were summarised according to topic.

9 articles were included that addressed 7 topics: (1) negative patient perceptions of insomnia and its impact, (2) failed self-care strategies, (3) initiating search for medical help, (4) attitudes regarding treatment options and service provision, (5) pattern of use variables, (6) withdrawal, (7) reasons for starting or continuing to use.

Psychological dependence, lack of support and denial/unawareness of patients regarding side effects prolongprescription. Educational strategies, increased availability of alternatives and wider, more specific dialogue with patients could support safer prescription.