An international comparison of deprescribing interventional studies: How to determine factors that contribute to translational deprescribing success?

Background: Globally, researchers have trialled implementation of deprescribing interventions to reduce the risk of patients’ medicine-related harm. The definition of deprescribing implementation success varies among studies. This heterogeneity makes it challenging to synthesise findings and identify gaps in the literature. Purpose: We conducted a systematized review of international deprescribing intervention studies to explore how deprescribing success was defined and achieved. Method: We searched scientific databases (e.g., EMBASE, Pubmed), grey literature (e.g., Google Scholar) and snowballing using backwards and forwards citation to determine five landmark articles eligible for inclusion. Our inclusion criteria included pharmacist-led, pragmatic, hybrid, randomised controlled trials (n>100). Participants included were older adults (60-97 years). We extracted data regarding key elements i.e. factors that contribute to deprescribing success of the studies. These included who conducted the intervention, a description and delivery methods of the implementation strategies employed, any government or health policy that promoted implementation of deprescribing into practice and outcomes measured. Results: We included five articles in the final analysis, conducted in North America, Europe and Australasia. All five studies were pharmacist-led with one study using pharmacists with prescribing rights. All five studies were multi-disciplinary. Four studies involved pharmacists and doctors; one study involved pharmacist prescribers and nurses. One study was conducted in residential aged care while the remaining four studies focussed on community-dwelling older adults. While all five studies involve the patient in the deprescribing decision, they varied in the constitution and delivery of their deprescribing implementation strategies. One study focused on patient empowerment by using a patient educational brochure. Two of the five studies provided training to their interventionists with one study providing evidence-based training. The other three studies relied on the pharmacists conducting medication reviews as part of their normal day-to-day scope of practice. All five studies were hybrid interventional studies and included both patient-centred health outcomes [e.g., falls],intermediate health outcome indicators (e.g. Drug Burden Index (DBI)) and process implementation outcomes, such as the uptake of deprescribing recommendations; with the highest percentage of uptake being 43% of discontinuation of sedative-hypnotics, the proportion of participants who used patient educational brochures and fidelity (adherence to the study protocol). Only one study mentioned government subsidised services to support conducting deprescribing medication reviews. Following up for adverse drug withdrawal events, at three or six months, occurred in all studies. Four of the five studies stated a longer follow up would have aided in fully realising clinical improvements. Conclusion: Our findings have shown that reporting about factors that may impact the success of deprescribing implementation strategies, to improve outcomes and reduce medicine-related harm in patients, varies. In order to synthesise findings, we recommend that reporting on all factors, discussed in this study, is more consistent amongst deprescribing research. Further work is needed to better understand specific factors that contribute to deprescribing “success”, such as employing specific implementation strategy components in certain settings.