Pharmacist-led, Physician-implemented interventions
Several small pilot studies in different outpatient clinic settings have
explored pharmacist-led deprescribing interventions with positive
outcomes.33,34,37,38,42 However, one RCT did not find
reduction of medication with addition of a pharmacist consult to a
geriatric outpatient clinic.31 A notable difference
with this study is that the patient was directed to the pharmacist
consult clinic after (rather than prior) to geriatrician consultation
and no formal deprescribing tool or process was described. The way in
which the pharmacist is incorporated into the team may have an effect on
efficacy.
Within an oncology outpatient unit, two small prospective studies
examined the benefit of pharmacist-led real time
deprescribing.33,34 Both demonstrated a significant
decrease in the prevalence of PIMS use based on validated tools and a
reduction in mean number of medications per patient. However, both
studies had considerable confounding factors and potential for bias. It
was noted that updating the medication list to remove medications no
longer taken by the patient was also considered as a deprescribing
intervention in one study.34 Similar pharmacist-led
studies have looked at identifying and reducing ‘drug-related problems
in oncology outpatients’.53,62 These did not meet the
criteria to be included in the systematic review, but it was noted that
that the most commonly identified drug-related problem was unnecessary
drug therapy and the most frequent recommendation was discontinuation of
a drug.
The feasibility of a pharmacist-led deprescribing intervention was also
examined in a small study completed within the setting of a memory
clinic. In this trial, a home medication review and polypharmacy
assessment was completed prior to the clinic visit and communicated to
the physician via a written report. Thirty of the 46 patients had
medications ceased; however, there was no overall significant change in
number of medications or PIMs noted 6-months after
intervention.37
A novel subacute medical outpatient unit was able to demonstrate
sustainable deprescribing with a pharmacist-led collaborative
intervention in a recent feasibility study.42 Another
study concluded that the addition of a pharmacist-led medication review
to usual care in an outpatient heart failure clinic may improve
drug-related problems and trend towards a reduction in medication
burden.38 Although unable to meet the criteria for
this systematic review, preliminary studies have also suggested benefits
from pharmacist led medication optimization for older patients within
diabetes clinics, HIV clinics, cardiology, palliative care, and
neurology clinics.59,63-66
Use of a pharmacist to complete a medication reconciliation and
polypharmacy assessment has notable advantages in terms of reducing
physician time and workload. Medication assessments are time consuming;
medication reviews of geriatric patients are documented to take between
20 and 140 minutes.53,62,67
In the reviewed studies, pharmacist medication assessments were either
completed remotely by review of electronic patient
records,38 face-to-face in the
clinic,31,33,34,42,60 or at a home
visit.37 Information sharing between the pharmacist
and patient is necessary to establish understanding of medications,
expectations they may have from treatment and previous (negative)
experiences, thus patient-record only reviews have significant
limitations.39 A medication review performed in the
home requires a longer duration, but the accuracy of the medication
history could be increased; Cross et al. noted that 76% of patients had
discrepancies between actual medication used (as obtained by the
pharmacist at the home visit) compared to the documented medication
history. A home medication review has previously been identified as a
positive way to improve prescribing and determine medication related
problems unknown to other healthcare providers.68,69
The ability of pharmacists to identify meaningful recommendations was
highlighted by an acceptance rate from the physician of 40% to
69%.37,38,42,53,62 Further research is needed to
identify the best methods of communicating recommendations, such as
verbal communication versus patient-physician written communication.