Discussion
Main findings
In this study, the medication review intervention with focus on
deprescribing was feasible as part of the developed Chronic Care Model
in real-life primary care. The intervention led to 255 medication
changes, of which more than 80% were deprescribing. The medication
changes were maintained during the 3-4 months follow-up period for
nearly all patients. At follow-up, we found that patients’ self-reported
health status had increased, while general condition and functional
level remained stable. Generally, similar trends were observed in the
sub-group analyses for both medication-related and health-related
measures.
Comparison with existing
literature
In recent years, several systematic reviews have synthesised the
evidence on the effectiveness of deprescribing interventions. These
reviews have focused on older people in general18 or
in different settings such as hospitals19, nursing
homes20,21, or primary care22,23.
Overall, the existing evidence suggests that deprescribing is feasible,
safe, and ,generally, effective in reducing the number of inappropriate
prescriptions22,24. A systematic review of
deprescribing trials in primary care showed that the proportion of
patients who successfully stopped their medication varied from 20% to
100%22. In 19 of the 27 included studies, more than
half of the participants had successfully stopped medications. In our
study, the majority of the medication changes were deprescribing.
Comparable to our findings, studies of deprescribing trials have shown
average discontinuations per patient between 2.8 and
4.425–28. Additionally, we found that medication
changes were maintained for nine of ten patients at 3-4 months follow-up
indicating successful deprescribing.
It is well-known that deprescribing can also lead to patient-harm in
terms of adverse drug withdrawal events or return of symptoms (e.g.,
increased pain levels or mood changes), for which the medication was
originally prescribed. Importantly, the majority of these harms can be
minimized or even prevented by using a patient-centred deprescribing
process with planning, tapering, and close monitoring during and after
medication withdrawal29. This was possible in our
study where a patient-centred deprescribing process was undertaken as
part of routine chronic care management in general practice in close
collaboration with the Centre for Health and Care in the Municipality of
Frederikshavn. We found that the intervention led to an increase in
self-reported health status from baseline to follow-up. Additionally,
general condition and functional level remained stable. In the subgroup
analyses, similar trends were seen in health-related outcomes among care
home residents and community-dwelling patient.
However, an interesting finding was the considerable, non-significant
increase in general condition among care home residents. Although
non-significant results should be interpreted with caution, this signals
that it may be possible to improve general condition through medication
reviews with focus on deprescribing in this vulnerable patient group.
Oppositely, no signal of change in general condition was observed among
community-dwelling patients, which may partly be explained by the high
proportion (80%) rated as “average or above” at baseline, which left
limited room for improvement.
Few studies have been able to demonstrate an effect of medication review
interventions on health-related outcomes of importance to patients. A
recent example is the DREAMeR study, in which community-dwelling older
persons with polypharmacy were offered patient-centred medication
reviews versus usual care30. This study showed
improved quality of life measured by the EQ-Visual Analogue Scale and
reduced health problems with a moderate to severe impact on daily life.
However, no effect was seen on quality of life measured by the EQ-5D-5L
or on total number of health problems. This highlights the complexity of
measuring improvement in the wellbeing of older and multimorbid
patients.
In a recent review by Ibrahim et al., the current evidence for
deprescribing among older people living with frailty was
reported24. Of six included studies, three reported a
positive impact on clinical outcomes such as depression, mental health
status, function, and frailty. However, results were mixed on falls and
cognition, and no significant impact was demonstrated on quality of
life24. The latter echoes previous findings across a
range of studies conducted in primary care using various quality-of-life
measures10,31–33. These mixed results call for
consideration regarding whether we are using the right measures to
capture potential benefits of interventions at a patient-level.
Moreover, they call for consideration regarding whether a lack of
statistically significant improvements in health-related outcomes should
be viewed more positively, as deprescribing without deterioration of
patient health may also be a desirable outcome.
Primary care as a setting for
deprescribing
In many countries, GPs are responsible for chronic care management in
primary care and the relational and managerial continuity in this
setting provide an optimal basis for deprescribing34.
In this real-life quality improvement project, the GPs in the GPF
decided to construct a new Chronic Care Model, including the
person-centred medication review intervention, to systematize the care
of patients with chronic diseases. It has been advocated to integrate
clinical practice guidelines more systematically into existing care
models to minimise the burden on health systems and primary care
providers35. Thus, the developed Chronic Care Model
employed in this study may have been an important enabler for
intervention implementation.
It was originally planned that a pharmacist employed by the municipality
would perform an initial medication review and present the findings for
the GP, who would then implement clinically relevant medication changes.
However, it soon became clear that the GPs performed the medication
reviews themselves and took ownership of the process in close
collaboration with the pharmacist, the nurses, and frontline staff at
the care homes. Ownership, flexibility, and autonomy of the primary care
providers have been identified as important enablers for implementation
of clinical practice guidelines35. Additional enablers
reported include a well-organised practice and clarification about the
role of primary care providers in disease management. Importantly,
multidisciplinary collaborations between different care levels should
also be considered to support the primary care providers’ recognition of
their role and responsibility for clinical practice guidelines
implementation35. In our study, this was attempted
through the cross-sectoral communication model that was established
alongside the Chronic Care Model.
The approach taken in our study might be inspirational to other Danish
municipalities as well as other countries with a similar organization of
primary care. However, our results might not be directly transferable,
as primary care medication management constitutes a complex health care
system. It encompasses different types of healthcare organization (e.g.,
home care, care homes, general practices) and health care providers
(e.g., nurses, pharmacists, GPs)36. Furthermore, both
private and public stakeholders exist in most countries and may be
highly dissimilar in their organization and available resources. Thus,
the specific context, in which the intervention is to be implemented,
should be fully considered, as adaptions may be needed to achieve
success and sustainability35.
Strengths and limitations
A major strength of this study was the real-world primary care setting,
in which the study was conducted. The recruitment and retention of
elderly patients in clinical trials provide many
challenges37. Thus, in contrast to the highly selected
patient groups often included in randomized controlled trials, our study
population more likely represent an unselected, real-world patient
population, which strengthen the generalizability of our results.
Further, it represents real-world implementation of a complex
intervention, which suggests that our intervention is feasible and
realistic in similar contexts. Even though the study was conducted
during the COVID-19 pandemic and the associated restrictions, it was
possible to implement the Chronic Care Model and include both care home
residents and home-dwelling patients in the intervention.
A major limitation of the study is that no control group was included to
compare results against usual care in similar GP clinics. Thus, no
causal links can be made between the intervention and our results.
Another limitation was the follow-up period of 3-4 months. As medical
conditions in older patients are unstable37, more
medication changes, incl. potential restarts as well as additional
deprescribing, would have been captured if we had used a longer
follow-up period. However, we expect that most potential harms of the
implemented medication changes would have been manifested during the 3-4
months period. Four care home residents died before follow-up. However,
by clinical evaluation it was
concluded that none of these deaths were directly related to the
intervention. Furthermore, the incidence of deaths was not higher than
expected in care home residents in general 38.
Conclusion
In this real-world quality improvement study settled in primary care, we
found that a systematic GP-led medication review intervention led to
deprescribing and increased self-reported health status without
deterioration of general condition or functional level among care home
residents and community-dwelling patients with chronic disease. These
results add new aspect to the existing literature and show that it may
be possible to improve patients´ self-perceived health status through
medication review interventions with a focus on deprescribing.