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.