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Effectiveness of Bundled Hyperpolypharmacy Deprescribing Compared With Usual Care Among Older Adults – A Randomized Clinical Trial

Herrinton LJ, Lo K, Alavi M, Alexeeff SE, Butler KM, Chang C, Chang CC, Chu VL, Krishnaswami A, Deguzman LH, Prausnitz S, Mason MD, Draves M. Effectiveness of Bundled Hyperpolypharmacy Deprescribing Compared With Usual Care Among Older Adults: A Randomized Clinical Trial. JAMA Netw Open. 2023 Jul 3;6(7):e2322505. doi: 10.1001/jamanetworkopen.2023.22505. PMID: 37428504; PMCID: PMC10334220.

The study by Herrinton et al. was a randomized clinical trial conducted from October 2020 to July 2022 within the Kaiser Permanente Northern California healthcare system. Its primary goal was to assess the effectiveness and safety of a bundled hyperpolypharmacy deprescribing intervention among older adults (76 years and older) using ten or more prescription medications. The study’s primary objectives were to measure changes in the number of medications prescribed and the occurrence of geriatric syndrome components reflecting adverse drug effects. Secondary endpoints included healthcare utilization and adverse drug withdrawal effects. The study sought to determine if this intervention could reduce medication burden and geriatric syndrome prevalence in this population, ultimately improving healthcare quality and patient outcomes.

The study involved two groups: the intervention group and the control group. The intervention group was a collaborative effort that utilized a physician-pharmacist partnership to implement evidence-based deprescribing practices. This comprehensive approach included shared decision-making using the SHARE approach and the CEASE deprescribing framework. Over 180 days, patients in the intervention group underwent pharmacist-led medication reviews, shared decision-making sessions, and gradual deprescribing, all with careful monitoring and follow-up. On the other hand, the control group represented usual care patients within the healthcare system who had access to existing deprescribing opportunities but did not receive the specific bundled intervention. Randomization occurred after obtaining physician approval, ensuring comparability between the two groups. The study employed a pragmatic design to mimic real-world conditions and aimed to assess the intervention’s impact on medication count, and geriatric syndrome diagnoses using electronic health record data from various clinical encounters. Statistical analyses included difference-in-differences models and adjustments for multiple testing, following the intention-to-treat principle and accounting for patients’ deprescribing outcomes and medication status during follow-up.

In this study, 2470 older adults, with a median age of 80 years, were randomized into intervention and usual care groups to assess a deprescribing intervention’s impact on medication count and geriatric syndrome diagnoses among those using ten or more medications. Both groups experienced slight medication reductions, with no significant differences between them, with mean adjustments of -0.4 [95% CI, -0.6 to -0.2] for the intervention and -0.4 [95% CI, -0.6 to -0.3] for usual care, with a p-value of .71. Geriatric syndrome prevalence also showed no significant change between the groups, with no differences observed in medical service utilization or adverse drug withdrawal effects. Furthermore, the study had limitations, including the possibility that the intervention may not have been appropriate for all patients using ten or more medications, potential timing issues in capturing intervention effects, lack of patient-reported outcomes, and potential data specificity gaps in electronic health records related to geriatric syndrome and adverse drug withdrawal effects.

Author Maisha Draves reflects on the potential implications for clinical practice or future research in the field of deprescribing for older adults, given the findings of no significant differences between the intervention and control groups:

“Hyperpolypharmacy is still a well-studied conundrum that leads to adverse events, side effects, and can decrease a patient’s quality of life. Deprescribing still has the potential to address this issue. However, we learned that age and number of medications alone are not enough to determine which patient or population may be best suited for a systematic approach. We look forward to refining both the subpopulations to consider as well as the systematic approach. We fail forward.”

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