The network is convening 4 special projects that address high-priority areas for deprescribing research. These will generate research products that advance the field of deprescribing research by synthesizing existing research on key topics, developing consensus about best practices, and gaining hands-on experience using health systems data to support future trials and observational studies. Each Working Group will do its work over a period of 1 to 2 years between 2019 and 2024.
High-Value Targets Working Group
Shelly Gray, PharmD, MS, University of Washington
Studies of deprescribing are heterogeneous, focusing on different types of medicines (e.g., reducing overall medication burden vs. stopping specific agents), different types of patients, and different care settings. It would be very helpful to know which areas are likely to yield the greatest benefit in improving patient outcomes so that limited healthcare resources and research funding can be efficiently directed. The objective of this working group is to compare the relative benefits of deprescribing interventions for different medication and patient population targets, and to develop consensus around which of these targets should be the highest priority for deprescribing interventions. Methods will comprise a systematic review and meta-analysis (where data permits) and an expert panel consensus development process. The systematic review and meta-analysis will focus on the comparative health benefits of deprescribing interventions for different types of patient populations, chronic conditions, and medications. An expert panel will be involved at key decision points, and once the literature is synthesized a modified Delphi process will be used to obtain consensus about high-priority target areas for deprescribing research and implementation.
Measures Working Group
Elizabeth Bayliss, MD, Kaiser Permanente Colorado & University of Colorado
Research on deprescribing is hindered by the inconsistent use of outcome measures across studies and by varying definitions of those measures. For example, it is difficult to evaluate the relative benefits of 2 types of interventions if they were evaluated using different outcome measures. The objective of this project is to identify measures and definitions used in deprescribing studies, to prioritize constructs most likely to be valuable for future deprescribing studies, and to develop operational definitions of these measures. This will include a focus on measures that can be assessed using routinely collected clinical data, as these will be essential for future pragmatic trials and large scale evaluations. First, the project team will catalog outcome measures and definitions used in published and ongoing experimental and quasi-experimental deprescribing studies. Based on the first-stage review, the Working Group will summarize existing measures, identify knowledge gaps such as insufficient validation or nonstandard definitions, and highlight areas ripe for measure development such as quantifying adverse drug withdrawal events and patient-important outcomes of deprescribing.22 Intermediate products will include a referenced compendium of deprescribing measures (as described above) and a peer-reviewed publication, both posted on the network website as resources for deprescribing investigators. Concurrently, an expert panel will ngage in a modified Delphi process to prioritize which constructs are most important (and practical) to use in future deprescribing research, and to develop operational definitions for selected high priority measures.
Data Harmonization Working Group
Sascha Dublin, MD, PhD, Kaiser Permanente Washington & University of Washington
Pragmatic deprescribing trials require use of electronic health record data to identify inclusion and exclusion criteria, characterize medication use, and measure important outcomes relevant to deprescribing. Developing and testing these methods across institutions and electronic health record systems will be necessary to ensure that measures can be broadly used with a reasonable degree of consistency across settings. The objective of this project is to develop and refine methods around creating, operationalizing, and implementing measures relevant to deprescribing studies across 5 institutions with different data systems. Activities that the sites will undertake include:
- provide a summary of availability of various types of data (e.g. demographics, medications, prescribers, diagnoses) including missingness and current state of harmonization with established common data models;
- summarize what is known about availability and completeness of data for the population served (e.g. sites of care with data available, ability to capture outside care and medications);
- produce descriptive tables for key variables of interest, including those identified as essential deprescribing measures by the Measures Working Group;
- demonstrate ability to produce a “waterfall” diagram showing application of inclusion and exclusion criteria to identify a cohort for a hypothetical deprescribing study; and
- identify, extract, and describe the frequencies of variables for selected essential constructs for deprescribing research in a representative cohort of older adults.
This will develop infrastructure for multi-site research, including preparing the study sites for future deprescribing trials, and inform creation of a “user’s guide” for using electronic health data for deprescribing research. The use of diverse sites and the user’s guide will lay a roadmap for other sites to participate in single- and/or multi-site research efforts in deprescribing that use electronic health data.
Communication Working Group
Terri Fried, MD, Yale University and VA Connecticut Health Care System
Patient-centered, culturally-sensitive communication is essential for patients and clinicians to arrive at a shared understanding of the benefits and harms of medications, and to make decisions about whether to stop medications. The objective of this project is to synthesize knowledge about deprescribing communication, and to develop a communication template based on best practices that clinicians can use when discussing deprescribing. The project team will conduct a systematic review of literature on communication in deprescribing and related areas of decision-making. Results from the literature review will be synthesized to develop a “state of the art” review describing the scope, characteristics, and best practices of communication around deprescribing, including the conduct and measurement of successful communication, with an emphasis on shared decision-making. Following this will be development of a communication aid template that clinicians can use to provide a structure for conversations about deprescribing. This will be developed using an iterative process of development and feedback with an advisory panel, and the template will undergo initial feasibility and acceptability testing in a clinical setting.