Reduce Harm and Waste - Overprescribing/Pharmacy

The approach to Reducing Harm and Waste in Realistic Medicine is to focus on value. When resources are limited, interventions are offered to those who will benefit most and who are more willing to accept risk and in these conditions it is more likely that high value healthcare is delivered. However as resources increase, interventions are offered to those less likely to benefit while the likelihood and magnitude of harm stays the same and in these conditions it is more likely that low or negative value healthcare is delivered. A personalised approach to care can help communicate these concepts for patients and help understand what benefit and risk mean for a patient’s personal situation. Personalised care can also reduce the impact of adverse events. Being Open is a best practice framework used in Scotland which creates an environment where patients and families feel supported and healthcare professionals and managers have the confidence to act appropriately. “Psychological harm to families is reduced when they experience compassionate care, their perspective is valued and when they are central to the review of care.” Being Open has also been used to prevent future harm when staff participate with the learning and improvement generated from the adverse event review reports. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]

During the pandemic some healthcare services were scaled back in order to minimise harm. Also, people were reluctant to access services and it is of concern that they have chosen to stay away. Routine care has been delayed and is now becoming more urgent. The organisation and delivery of care will need to be reviewed as demand increases. Shared decision making and personalising care will help people make an informed choice about their care and allow effective and efficient use of services, reducing harm and waste. Modernising Patient Pathways Program (MPPP) is transforming outpatient services across Scotland by ensuring the optimal pathway is chosen at first point of contact. Active Clinical Referral Triage (ACRT) has the potential to reduce waiting times by eliminating unnecessary face to face appointments.  Discharge Patient-Initiated Review (PIR) encourages patient independence and helps to avoid unwarranted use of our clinical resources, as well as our patients' valuable time, by avoiding routine "check-ups”. [The Scottish Government. The Chief Medical Officer for Scotland’s Annual Report 2020-21: Recover, Restore, Renew. Published 2021. https://www.gov.scot/publications/cmo-annual-report-2020-21/ ]

Value can be assessed in many different ways and can include cost-effectiveness analysis, economic analysis, disinvestment, and reducing overuse and overprescribing. Below is a selection of journal articles and reports which are about pharmaceuticals, prescribing, and overprescribing in healthcare.  If you are looking to answer a specific question please submit a literature search request at the link above.  If you would like to be alerted when new content is available here then please sign in and select Follow.  You are welcome to leave comments and suggestions below in the comments section.

Articles

BENNETT F., et al, 2021. Overprescribing and rational therapeutics: Barriers to change and opportunities to improve. British journal of clinical pharmacology, 87(1), pp. 34-38.

WALKER, L.E. and MANGONI, A.A., 2021. Avoiding harm from overprescribing: What are the challenges and how do we overcome them?. British journal of clinical pharmacology, 87(1), pp. 6-8.

ABDULLA D.A., et al, 2020. Deprescribing: Barriers, benefits, and harms. International Journal of Pharmaceutical Research and Allied Sciences, 9(3), pp. 110-114.
Polypharmacy, which is the practice of prescribing five or more medicines to the same patient is associated with many problems like adverse drug reactions and poor adherence to therapy and can be harmful. Recently, the term deprescribing is used to describe the systematic process of identifying and discontinuing medicines in situations in which potential or existing harms outweigh potential or existing benefits for the seek of individual patient care goals and preferences. Many studies assessed the attitude of patients or perceptions of health care practitioners towards deprescribing, others evaluated barriers or factors affecting deprescribing. Since the practice of deprescribing is growing, this study aimed to review the harms, benefits, and barriers of deprescribing. Some studies reported that patients may be interested in withdrawing one or more of their medicines if advised by their treating doctors and at the same time costs and experiencing medication adverse effects may result in a willingness to decrease the number of medications taken. Harms that may occur due to deprescribing can be minimized or even prevented by using a structured and patient-specific deprescribing process with proper planning and careful monitoring during and after medication withdrawal.

ANDERSON T.S., et al, 2020. Implementing a Proactive Deprescribing Approach to Prevent Adverse Drug Events. Journal of General Internal Medicine, 35(12), pp. 3694-3696.

CAVE, J.A., 2020. Polypharmacy and deprescribing: just ask the patient. (Editorial) Drug & Therapeutics Bulletin, 58(1), pp. 2.

DAVIES L.E., et al, 2020. Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews. Journal of the American Medical Directors Association, (pagination), pp. ate of Pubaton: 2020.
Objective: Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people.

DIGGINS, K., 2020. Integrating the 2019 AGS Beers Criteria into NP practice: A stepwise approach. The Nurse practitioner, 45(3), pp. 40-43.
The American Geriatrics Society Beers Criteria, designed to prevent the prescription of potentially inappropriate medications to older adult patients, were updated in 2019. This article provides a stepwise protocol on how to incorporate the Beers Criteria guidelines into NP practice using a case study model.

EARL, T.R., et al, 2020. Using Deprescribing Practices and the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria to Reduce Harm and Preventable Adverse Drug Events in Older Adults. Journal of patient safety, 16(3S Suppl 1), pp. S23-S35. (Systematic review)
The deprescribing interventions involved decision support tools, educational interventions, and medication reviews by pharmacists and/or providers. Deprescribing studies primarily examined the effect of interventions on process outcomes and observed reductions in polypharmacy, often significantly. A few studies also examined clinical and economic outcomes. Studies of the use of the STOPP screening criteria most commonly reported changes in PIMs, as well as some economic outcomes. CONCLUSIONS: Deprescribing interventions and interventions using the STOPP criteria seem effective in reducing polypharmacy and PIMs in older adults, respectively.

LEE J.Q., et al, 2020. Intervention elements to reduce inappropriate prescribing for older adults with multimorbidity receiving outpatient care: A scoping review. BMJ Open, 10(8) , pp. e039543.
Data synthesis and analysis was based on the BCW framework. Results Of 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: education', persuasion', training', environmental restructuring' and enablement'. Conclusion PIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.

O'MAHONY M.S. and PARBHOO, A., 2020. Deprescribing in older people. British journal of hospital medicine (London, England : 2005), 81(1), pp. 1-9.
Polypharmacy and multimorbidity are both currently rising. The number of medicines taken is the single biggest predictor of adverse drug events. Deprescribing is an approach to managing polypharmacy and reducing adverse outcomes. Multiple international evidence-based guidelines are emerging to promote discontinuation of high-risk medications, and use of alternative medical and non-pharmacological management. This review outlines the evidence base behind deprescribing, and suggests some pragmatic approaches to decision making around medication review.

O'MAHONY, D., 2020. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Review of Clinical Pharmacology, 13(1), pp. 15-22.
This review examines the clinical trial evidence pertaining to STOPP/START criteria as an intervention.  Two large-scale multi-center trials (SENATOR and OPERAM) examined the impact of computer-generated STOPP/START criteria on incident ADRs (SENATOR) and drug-related hospitalizations (OPERAM) in multi-morbid older people. Results of these trials will be publicized in 2020. Expert opinion: Applying STOPP/START criteria improves clinical outcomes in multi-morbid older people. Electronic deployment of STOPP/START criteria is a substantial technical challenge; however, recent clinical trials of software prototypes demonstrate feasibility. Even with well-functioning software for the application of STOPP/START criteria, the need remains for face-to-face interaction between attending clinicians and appropriately trained personnel (likely pharmacists) to explain and qualify specific STOPP/START recommendations in individual multi-morbid older patients. Such interaction is essential for the implementation of relevant STOPP/START recommendations.

PAYNE, R., 2020. The key challenges of deprescribing. Prescriber, 31(3), pp. 4.

PAYNE, R.A., 2020. Polypharmacy and deprescribing. Medicine (United Kingdom), epub ahead of print
Polypharmacy is a common issue in clinical practice, with 20% of adults given >=5 regular medications. It particularly impacts elderly individuals and those with multiple morbidities, and is worsened by single-disease, guideline-driven prescribing and service pressures. Although sometimes appropriate, it can also be problematic, associated with a range of adverse outcomes including hazardous prescribing, excess treatment burden, poor quality of life, higher health service use, and increased morbidity and mortality. Polypharmacy management is complex because of the presence of multiple problems, competing priorities and clinical uncertainty. The mainstay of management is currently medication review, which should be holistic and patient centred, and employ shared decision-making. Key elements include addressing unnecessary prescribing, ineffective prescribing, drug safety and cost-effectiveness. Deprescribing is a core means of reducing polypharmacy, although there are several important barriers to its delivery, including a weak evidence base. In the longer term, preventing inappropriate polypharmacy requires a significant shift in prescribing culture, and is likely to take considerable time to achieve.

REEVE, E., 2020. Deprescribing tools: a review of the types of tools available to aid deprescribing in clinical practice. Journal of Pharmacy Practice and Research, 50(1), pp. 98-107.
A number of tools have been developed with the purpose of aiding health professionals to deprescribe in regular practice. The types of tools vary significantly in their form and include tools to aid in the overall process of deprescribing (such as generic frameworks and drug-specific deprescribing guidelines) as well as tools that may assist in a specific part of the process (such as identifying inappropriate medications or engaging the patient). While many tools are available, most provide little (if any) information on how they were developed, and limited implementation research has been conducted. This paper provides an overview of the types of available tools and how they might be used in clinical practice.

SAWAN M., et al, 2020. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Review of Clinical Pharmacology, 13(3), pp. 233-245.
Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.

SCOTT, S., et al, 2020. A practitioner behaviour change intervention for deprescribing in the hospital setting. Age & Ageing, epub ahead of print
The panel selected five intervention components supporting engagement with deprescribing: an organisational action plan to prioritise deprescribing, two training activities to address pharmacists' beliefs about negative deprescribing consequences, restructuring pharmacists' working patterns to facilitate their contribution to deprescribing decisions, and sharing experiences of successfully engaging patients/family in deprescribing conversations to support others to do the same. A sixth component was selected to sustain engagement with deprescribing through measuring and sharing deprescribing activity achieved between teams. CONCLUSIONS: deprescribing interventions targeting geriatricians' and pharmacists' behaviour in the English hospital context should include the six characterised components. A component to sustain deprescribing activity is a notable omission from previously reported deprescribing interventions and may explain their failure to maintain efficacy beyond the short-term trial period. Copyright © The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.

WEIR, K.R., 2020. Preferences around communication and decision-making in deprescribing. Journal of Pharmacy Practice and Research, 50(6), pp. 524-527.

BAUMGARTNER, A.D., et al, 2019. Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation? Journal of Clinical Pharmacy & Therapeutics,
“In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes. These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions due to negative results, when the correct interpretation might be that they failed in implementation. In other words, they were 'lost in translation'. Studies that rigorously examine and report on the implementation process are needed to tease apart this important distinction.”

DHARMARAJAN T.S., et al, 2019. Deprescribing as a Clinical Improvement Focus. Journal of the American Medical Directors Association, epub ahead of print
Objectives: Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process.

MANGIN, D. and GARFINKEL, D., 2019. Foreword to the first special collection: Addressing the invisible iatrogenic epidemic: the role of deprescribing in polypharmacy and inappropriate medication use. Therapeutic Advances in Drug Safety, 10, pp. 2042098619883156.

PRUSKOWSKI J.A., et al, 2019. Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature. Drugs and Aging, 36(12), pp. 1097-1110.

SCOTT, S., et al, 2019. Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists. Age & Ageing, 49(1), pp. 102-110.
“54 geriatricians and pharmacists representing four UK hospitals attended 8 focus groups. A topic guide was used to invite discussions about barriers and enablers to deprescribing. Geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists' working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. The behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts. “ Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society.

WOODFORD H.J. and FISHER, J., 2019. New horizons in deprescribing for older people. Age and Ageing, 48(6), pp. 768-775.
“Deprescribing has gained interest recently, driven by an ageing population seeing an increasing number living with multiple long-term conditions. This, coupled with disease-specific guidelines derived from clinical trials in younger people, has led to an increase in exposure to polypharmacy and the associated therapeutic burden. Older people, especially those living with frailty, tend to experience lower efficacy of these medications along with a higher risk of drug adverse effects. Explanations for these differences include the physiological effects of frailty, drug-drug interactions, drug-disease interactions and reduced medication adherence. Adverse drug reactions often go unnoticed and can trigger further prescribing. Certain medications have been recognised as potentially inappropriate for people with frailty, yet their use remains common. Evidence suggests that many older people are open to the concept of reducing medications. Deprescribing should be based around a shared decision-making approach. Trials to date have suggested that it can often be achieved without harm. To date, there are few data to support improvements in hospitalisation or mortality rates. However, there is some evidence that it may reduce polypharmacy, improve medication adherence, reduce financial costs and improve quality of life. In the future, it will be necessary to grow the evidence base and improve public and clinician awareness of the potential benefits of deprescribing. It will require excellent team working and communication between all of those involved in the prescribing and administration of medications, also supported by improved healthcare informatics. Non-pharmacological approaches will need to be promoted. Fewer drugs is not less care.”

Berdud, M., Chalkidou, K., Dean, E.  (2019)  The future of global health procurement: Issues around pricing transparency.  The Office of Health Economics This OHE Research Paper focuses on the role that price transparency may play in the efficient and effective procurement of medicines by middle and low income countries.  Will making prices publicly available make procurement more efficient and cost effective medicines more accessible?

BLACK, C.D., et al, 2019. The Health System Costs of Potentially Inappropriate Prescribing: A Population-Based, Retrospective Cohort Study Using Linked Health Administrative Databases in Ontario, Canada. PharmacoEconomics Open, Conclusions: Potentially inappropriate prescribing  (PIP) in older adults is a significant source of health system costs from healthcare service use beyond medication costs, with a significant portion of hospitalizations and ED visit costs attributable to PIP. Future work should focus on identifying strategies and priorities for intervention.

FAJARDO, M.A., et al, 2019. Availability and readability of patient education materials for deprescribing: An environmental scan. British journal of clinical pharmacology, 85(7), pp. 1396-1406. Conclusions: “Over 1/3 of deprescribing PEMs present potential benefits and harms of deprescribing indicating most of the freely available materials are not balanced. Most PEMs are pitched above average reading levels making them inaccessible for low health literacy populations.”

LE BOSQUET, K., et al, 2019. Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing. Pharmacy : A Journal Of Pharmacy Education And Practice, 7(3),
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.

Chalmers, D., Poole, C., Webster, S., et al (2018) Assessing the healthcare resource use associated with inappropriate prescribing of inhaled corticosteroids for people with chronic obstructive pulmonary disease (COPD) in GOLD groups A or B: an observational stidy using the Clinical Practice Research Datalink (CRPD).  Respiratory Research 19(1):63 Conclusion: The data suggests that ICS use in GOLD A and B COPD patients is not associated with a benefit in terms of healthcare resource use compared to non-ICS bronchodilator based therapy; using ICS according to GOLD recommendations may offer an opportunity for improving patient care and reducing resource use

Greise-Mammen, N., Heisberger, KE., Meeerlie, M., et al (2018) PCNE definition of medication review: reaching agreement. International Journal of Clinical Pharmacy 40(5): 1199-1208.

Conclusion:  Involvment of an international community from research and practice and use of a systematic process led to an afreement on the term medication review and on classification valide for all settings and professions.

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Reports

IHI Blog, Leslie Pelton, September 10 2018.  Deprescribing can mean fewer Opioids, more grateful patients  (last accessed 19/10/2018). 

Miani, C., Martin, A., Exley, J., et al. (2017)  Clinical effectiveness and cost-effectiveness of issuing longer versis shorter duration (3 months vrs 28 day) prescriptions in patients with chronic conditions: systematic review and economic modelling.  Health Technology Assessment 21 (78): 1-128.  Although the quality of evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28 day prescriptions in patients with chronic conditions in primary care.

McCarthy D. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017.

A multidisciplinary team of clinical experts in Ottawa, Canada, created a credible, low-cost process for developing and implementing evidence-based deprescribing guidelines and tools for assessing, tapering, and stopping medications that may cause harm or no longer benefit patients. Although the guidelines led primary care teams to consider approaches for identifying such medications and engaging patients in conversations about discontinuing them, the intervention has thus far been more successful in long-term care settings, where it strengthened team-based medication reviews in fulfillment of routine quality improvement and reporting requirements.

For more information and to obtain the full text click here.

Public Health England, 2015. Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England. Public Health England, July 2015  (last accessed 11/09/2015)

“Comparison with epidemiological studies of mental illness in adults with learning disabilities suggests that 13% of the population (roughly 23,800 people) are being prescribed antipsychotics in the absence of a psychotic illness, and 10% antidepressants in the absence of an affective illness

(roughly 19,500 people). Allowing for overlap, which is common, we estimate that between 30,000 and 35,000 adults with a learning disability in England are taking one or both of these types of drug

in the absence of the conditions for which they are indicated. Prescribing of antipsychotics and antidepressants to children and young people is much less common.” (page 6-7)