Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line.

Background: Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods: Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results: Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion: Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.

Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks.

INTRODUCTION: Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED: Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION: Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.

Impact of oral bisphosphonate drug holiday on mortality following hip fracture: a population-based cohort study.

CONTEXT: Current clinical guidelines recommend a drug holiday after extended use of oral bisphosphonates. However, no studies have investigated the impact of drug holidays before hip fractures on post-fracture mortality. OBJECTIVE: To investigate the effect of drug holiday on post-fracture mortality in patients with extended use of oral bisphosphonates. DESIGN: Retrospective population-based cohort study. SETTING: All patients with hip fractures in Victoria, Australia from 2014-18. PATIENTS: Patients adherent to oral alendronate or risedronate for ≥5 years prior to hip fracture. INTERVENTION(S): Group-based trajectory modelling categorized patients into different bisphosphonate usage after 5-year good adherence. MAIN OUTCOME MEASURE(S): Post-fracture mortality. RESULTS: We identified 365 patients with good adherence (medication possession ratio ≥80%) to oral alendronate/risedronate for ≥5 years. Most patients (69%) continued to use oral bisphosphonates till admission for hip fracture; 17% had discontinued for one year and 14% had discontinued for two years. Post-fracture mortality was higher in patients who had discontinued risedronate for one year (Hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.24-4.53) and two years (HR 3.08, 95% CI 1.48-6.41) prior to hip fracture. No increase or decrease in post-fracture mortality was observed in patients who had discontinued alendronate for one year (HR 0.59, 95% CI 0.29-1.18) or two years (HR 1.05, 95% CI 0.57-1.93) prior to hip fracture. CONCLUSIONS: Post-fracture mortality is higher in people who discontinue risedronate, but not alendronate, for 1 or 2 years after being adherent to treatment for at least 5 years. The type of bisphosphonate may be a factor to consider when planning drug holidays.

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review.

BACKGROUND: The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use). METHODS: We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted. RESULTS: From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy. CONCLUSION: Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

Prescriber Acceptability of a Direct-to-Patient Intervention for Benzodiazepine Receptor Agonist Deprescribing and Behavioural Management of Insomnia in Older Adults.

Behavioural treatments are recommended first-line for insomnia, but long-term benzodiazepine receptor agonist (BZRA) use remains common and engaging patients in a deprescribing consultation is challenging. Few deprescribing interventions directly target patients. Prescribers' support of patient-targeted interventions may facilitate their uptake. Recently assessed in the Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, Sleepwell (mysleepwell.ca) was developed as a direct-to-patient behaviour change intervention promoting BZRA deprescribing and non-pharmacological insomnia management. BZRA prescribers of YAWNS NB participants were invited to complete an online survey assessing the acceptability of Sleepwell as a direct-to-patient intervention. The survey was developed using the seven construct components of the theoretical framework of acceptability (TFA) framework. Respondents (40/250, 17.2%) indicated high acceptability, with positive responses per TFA construct averaging 32.3/40 (80.7%). Perceived as an ethical, credible, and useful tool, Sleepwell also promoted prescriber-patient BZRA deprescribing engagements (11/19, 58%). Prescribers were accepting of Sleepwell and supported its application as a direct-to-patient intervention.

Trajectories of oral bisphosphonate use after hip fractures: a population-based cohort study.

Bisphosphonates prevent future hip fractures. However, we found that one in six patients with hip fractures had a delay in bisphosphonate initiation and another one-sixth discontinued treatment within 12 months after discharge. Our results highlight the need to address hesitancy in treatment initiation and continuous monitoring. PURPOSE: Suboptimal antiresorptive use is not well understood. This study investigated trajectories of oral bisphosphonate use following first hip fractures and factors associated with different adherence and persistence trajectories. METHODS: We conducted a retrospective study of all patients aged ≥ 50 years dispensed two or more bisphosphonate prescriptions following first hip fracture in Victoria, Australia, from 2012 to 2017. Twelve-month trajectories of bisphosphonate use were categorized using group-based trajectory modeling. Factors associated with different trajectories compared to the persistent adherence trajectory were assessed using multivariate multinomial logistic regression. RESULTS: We identified four patterns of oral bisphosphonate use in 1811 patients: persistent adherence (66%); delayed dispensing (17%); early discontinuation (9%); and late discontinuation (9%). Pre-admission bisphosphonate use was associated with a lower risk of delayed dispensing in both sexes (relative risk [RR] 0.28, 95% confidence interval [CI] 0.21-0.39). Older patients ( ≥ 85 years old versus 50-64 years old, RR 0.38, 95% CI 0.22-0.64) had a lower risk of delayed dispensing. Males with anxiety (RR 9.80, 95% CI 2.24-42.9) and females with previous falls had increased risk of early discontinuation (RR 1.80, 95% CI 1.16-2.78). CONCLUSION: Two-thirds of patients demonstrated good adherence to oral bisphosphonates over 12 months following hip fracture. Efforts to further increase post-discharge antiresorptive use should be sex-specific and address possible persistent uncertainty around delaying treatment initiation.

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations.

BACKGROUND: Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. OBJECTIVE: We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). DESIGN: Retrospective cohort study from 2015 to 2019. PARTICIPANTS: Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). MAIN MEASURES: Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. KEY RESULTS: The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. CONCLUSIONS: The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.

Systematic Review of Psychotropic Adverse Drug Event Monitoring Tools for Use in Long-Term Care Facilities.

OBJECTIVES: To evaluate properties of psychotropic adverse drug event (ADE) monitoring tools intended for use in long-term care facilities. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Adults aged 18 years and older in nursing homes and other long-term care facilities. METHODS: Medline, CINAHL, Embase, and PsycInfo were searched from inception to August 2022 for studies reporting the development, validation, or application of tools to monitor psychotropic ADEs. Screening, data extraction, and quality assessment were performed independently by 2 authors. Each tool was assessed under the domains of test-retest reliability, interrater reliability, content validity, and construct validity. RESULTS: Eight studies that described 6 tools were included. Tools were developed in Wales (n = 2), United States (n = 1), Ireland (n = 1), Canada (n = 1), and Singapore (n = 1). Tools monitored 4 to 95 items related to antipsychotics (n = 6 tools), antidepressants (n = 4), benzodiazepines or hypnotics (n = 4), antiepileptics (n = 4), and dementia medications (n = 1). Tools commonly monitored sedation, tiredness, or sleepiness (n = 6), falls (n = 4), and tremor or extrapyramidal symptoms (n = 4). Tools were designed for application by nurses (n = 4), during family conferences (n = 1), and by general medical practitioners before repeat prescribing (n = 1). Two tools were reported to require 10 to 60 minutes to administer. Four tools were determined to have adequate content validity and 2 tools adequate interrater reliability. No tools reported test-retest reliability or construct validity. CONCLUSIONS AND IMPLICATIONS: Six published psychotropic ADE monitoring tools are heterogeneous in design and intended application. Existing tools are predominately designed for application by nurses with or without direct involvement of the wider multidisciplinary team. Further research is needed into models of care that facilitate psychotropic ADE monitoring in the long-term care facility setting, and the extent to which application of specific tools is associated with reduced medication-related harm.

Hip fracture incidence and post-fracture mortality in Victoria, Australia: a state-wide cohort study.

Hip fractures are a major public health concern. Number of hip fractures cases increased by 20% from 2012 to 2018. Factors associated with post-fracture mortality included men, those who are frail, living in a non-metropolitan region, or residing in a residential aged care facility. Our results are useful for planning healthcare interventions. PURPOSE: Hip fractures are a major public health concern in Australia. Data on hip fracture incidence and mortality are needed to plan and evaluate healthcare interventions. The aims of the study were to investigate (1) the time-trend in absolute number and incidence of first hip fractures, and (2) factors associated with mortality following first hip fractures in Victoria, Australia. METHODS: A state-wide cohort study of all patients aged [Formula: see text] 50 years admitted to a Victorian hospital for first hip fracture between July 2012 and June 2018. Annual age-standardized incidence rates were calculated using population data from Australian Bureau of Statistics. Multivariate negative binomial regression was used to investigate factors associated with post-fracture mortality. RESULTS: Overall, 31,578 patients had a first hip fracture, of whom two-thirds were women and 47% were [Formula: see text] 85 years old. Absolute annual numbers of first hip fractures increased by 20%. There was no significant change in age- and sex-adjusted incidence. In total, 8% died within 30 days and 25% within 1 year. Factors associated with 30-day mortality included age (≥ 85 years old versus 50-64 years old, mortality rate ratio [MRR] 8.05, 95% confidence interval [CI] 5.86-11.33), men (MRR 2.11, 95% CI 1.88-2.37), higher Hospital Frailty Risk Scores (high frailty versus no frailty, MRR 3.46, 95% CI 2.66-4.50), admission from a residential aged care facility (RACF) (MRR 2.28, 95% CI 1.85-2.82), and residing in a non-metropolitan region (MRR 1.22, 95% CI 1.09-1.38). The same factors were associated with 1-year mortality. CONCLUSION: The absolute increase in hip fractures highlights the need for interventions to reduce fracture risk, especially for those at higher risk of post-fracture mortality, including men and those who are frail, living in a non-metropolitan region, or residing in a RACF.

Effectiveness and cost analysis of methods used to recruit older adult sedative users to a deprescribing randomized controlled trial during the COVID-19 pandemic.

Background: Recruitment to clinical trials is a challenge for researchers that became more pronounced because of COVID-19 public health protective measures, especially with respect to studies enrolling older adults. We completed an effectiveness and cost analysis of the recruitment methods used in The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, a randomized controlled trial of a deprescribing intervention that recruited older adults with chronic use of sedatives during the pandemic. Methods: Study recruitment began during the COVID-19 pandemic. Strategies included random digit dialing (RDD), a targeted mail campaign and advertising through newspapers, online platforms (Google and Facebook), and television. Other awareness raising and recruitment strategies involved seniors' organizations, pharmacies, television news stories, and referrals. Recruitment effectiveness and cost analysis involved enrollment rate (ER), cost per randomized participant (CPRP), fractional cost (FC), fractional enrollment (FE), fractional enrollment-cost ratio (FEC), and efficacy index (EI) calculations. Results: There were 1295 interested older adults with 594 randomized into the study for an enrollment rate of 46%. The efficacy index (EI) was highest for Facebook ads (EI = 0.683) followed by television (EI = 0.426), and newsprint ads (EI = 0.298). The cost of RDD was highest per randomized participant at $1117.90 and produced the lowest EI (0.013). Conclusion: Facebook ads had the best efficacy index for recruiting older adults to the YAWNS NB study during the COVID-19 pandemic and television ads produced the most enrollments. RDD was expensive and yielded few recruits. Recruitment costs can be significant for recruiting community-dwelling older adults. This experience can inform recruitment strategy and budget development for future community studies enrolling older adults, especially in the context of the COVID-19 pandemic.

Deprescribing proton pump inhibitors.

BACKGROUND: Proton pump inhibitors (PPIs) are indicated for disorders including peptic ulcer disease and gastro-oesophageal reflux disease; however, they are often used for longer and at higher doses than recommended, or for indications that are not supported by evidence. OBJECTIVE: The aim of this article is to outline evidence-based approaches to deprescribing PPIs. DISCUSSION: PPIs are generally well tolerated; however, use beyond eight weeks is rarely indicated and increases the risk of adverse events. PPI deprescribing should be considered when there is no indication for long-term therapy. Evidence supports a patient-centred approach to PPI deprescribing involving stepping down the dose before ceasing or switching to pro re nata (PRN; 'as needed') use. Abrupt PPI discontinuation may result in short-term rebound acid hypersecretion that can mimic symptom return. This can be minimised with gradual dose tapering prior to discontinuation and managed with PRN treatment. Prescribers should discuss the rationale for PPI deprescribing and involve patients in developing the deprescribing plan.

A protocol for a randomized controlled trial comparing Sleepwell, EMPOWER, and treatment-as-usual for benzodiazepine receptor agonist discontinuation in older adults: the your answers when needing sleep in New Brunswick (YAWNS NB) study.

Background: Chronic benzodiazepine receptor agonist (BZRA) use among older adults is a public health concern given cognitive and physical risks. One in four older adults in New Brunswick, Canada, is a long-term user of BZRAs. Previous studies using a direct-to-patient approach as the primary intervention target have shown promise in reducing BZRA use. The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study aims to reduce the long-term use of BZRAs in older adults and increase the use of cognitive behavioural therapy for insomnia (CBTi), which is the recommended first line treatment. Methods: The trial (ClinicalTrials.gov registration NCT04406103) is a three arm, open-label, parallel randomized controlled trial in NB, Canada. Eligible participants 65 years and older using BZRAs long-term will be randomly allocated to: the Eliminating Medications through Patient Ownership of End Results (EMPOWER) information package group; the Sleepwell information package group; or treatment-as-usual (TAU). Information packages will be mailed via Canada Post. The primary outcome of BZRA discontinuation at 6 months will be compared across groups. Secondary outcomes include participants with ≥25% BZRA dose reduction, and switching to newly prescribed alternate sedative-hypnotics. Several exploratory outcomes will also be examined. Discussion: Targeting participants with information packages informing them of appropriate use, dangers, and approaches to reducing BZRA use and increasing CBTi use may be beneficial in a region of Canada with the highest rate of chronic BZRA use in older adults. Comparing information packages and TAU will provide insights into the effectiveness of direct-to-patient interventions for BZRA reduction.

Health professionals' perspectives regarding polypharmacy in older patients with cancer: A mixed-design exploratory study.

OBJECTIVES: Older patients with cancer often present with multimorbidity and polypharmacy, but there is little information on the challenges these conditions raise. We aimed to describe health professionals' practice, perceptions and needs related to polypharmacy for older adults receiving cancer treatment. MATERIALS AND METHODS: We performed a mixed-design exploratory study. Phase 1 involved an online survey of 16 Likert-scale or multiple choices questions regarding polypharmacy and medication management for older patients with cancer. Phase 2 comprised two focus groups with oncology health professionals to learn about their perceptions and needs regarding medication management during cancer treatments. RESULTS: A total of 54 health professionals responded to the survey (nurses = 25; pharmacists = 21; physicians = 6; other = 2). Half of them always or often felt that medication is a significant burden for patients but only a quarter always or often addressed the possibility of stopping medications. Ten health professionals participated in the focus groups. The normalization of the quantity of medications used in relation with aging, as well as the lack of older adults' knowledge about their medication were reported. Other barriers to deprescribing included lack of time and expertise, and issues with communication between health professionals. CONCLUSION: Although polypharmacy is a concern for many health professionals, most do not discuss deprescribing with older patients with cancer. Normalization of medication use, both by older adults and health professionals, stands as a significant barrier to critical medication review. The development of clinical tools could facilitate identification of circumstances where deprescribing is appropriate and help reduce associated barriers.

Rates of PRN Medication Administration in Australian Residential Aged Care.

OBJECTIVE: To investigate administration of pro re nata (PRN) medications and nurse-initiated medications (NIMs) in Australian aged care services over a 12-month period. DESIGN: Twelve-month longitudinal audit of medication administrations. SETTING AND PARTICIPANTS: Three hundred ninety-two residents of 10 aged care services in regional Victoria, Australia. METHODS: Records of PRN and NIM administration were extracted from electronic and hard copy medication charts. Descriptive statistics were used to calculate medication administration per person-month. Poisson regression was used to estimate predictors of PRN administration. RESULTS: Over a median follow-up of 12 months (interquartile range 10-12 months), 93% of residents were administered a PRN medication and 41% of residents an NIM on 21,147 and 552 occasions, respectively. The mean number of any PRN administration was 5.85 per person-month. The most frequently administered PRN medications per person-month were opioids 1.54, laxatives 0.96, benzodiazepines 0.72, antipsychotics 0.48, paracetamol 0.46, and topical preparations 0.42. Three-quarters of residents prescribed a PRN opioid or PRN benzodiazepine and two-thirds of residents prescribed a PRN antipsychotic had the medication administered on 1 or more occasions over the follow-up. CONCLUSIONS AND IMPLICATIONS: Most residents were administered PRN medications. Administration was in line with Australian regulations and institutional protocols. However, the high frequency of PRN analgesic, laxative, and psychotropic medication administration highlights the need for regular clinical review to ensure ongoing safe and appropriate use.

Economic Evaluation of Sedative Deprescribing in Older Adults by Community Pharmacists.

BACKGROUND: Sedative use in older adults increases the risk of falls, fractures, and hospitalizations. The D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), pragmatic randomized clinical trial demonstrated that community-based, pharmacist-led education delivered simultaneously to older adults and their primary care providers reduce the use of sedatives by 43% over 6 months. However, the associated health benefits and cost savings have yet to be described. This study evaluates the cost-effectiveness of the D-PRESCRIBE intervention compared to usual care for reducing the use of potentially inappropriate sedatives among older adults. METHODS: A cost-utility analysis from the public health care perspective of Canada estimated the costs and quality-adjusted life-years (QALYs) associated with the D-PRESCRIBE intervention compared to usual care over a 1-year time horizon. Transition probabilities, intervention effectiveness, utility, and costs were derived from the literature. Probabilistic analyses were performed using a decision tree and Markov model to estimate the incremental cost-effectiveness ratio. RESULTS: Compared to usual care, pharmacist-led deprescribing is less costly (-$1392.05 CAD) and more effective (0.0769 QALYs). Using common willingness-to-pay (WTP) thresholds of $50 000 and $100 000, D-PRESCRIBE was the optimal strategy. Scenario analysis indicated the cost-effectiveness of D-PRESCRIBE is sensitive to the rate of deprescribing. CONCLUSIONS: Community pharmacist-led deprescribing of sedatives is cost-effective, leading to greater quality-of-life and harm reduction among older adults. As the pharmacist's scope of practice expands, consideration should be given to interprofessional models of remuneration for quality prescribing and deprescribing services.

The role of medication advisory committees in residential aged care services.

BACKGROUND: There is increasing international interest in initiatives to reduce medication-related harm and preventable hospitalizations in residential aged care services (RACS). The Australian Government recommends that RACS establish multidisciplinary Medication Advisory Committees (MACs). No previous research has specifically investigated the structures and functioning of MACs. OBJECTIVES: To explore the current structures and functioning of MACs, and identify opportunities for MACs to better promote safe and effective medication use. METHODS: Semi-structured interviews and focus groups were conducted with a maximum variation sample of health professionals (n = 44) across four health services operating across 27 RACS in rural and regional Victoria, Australia. Qualitative data were analyzed using deductive and inductive content analyses. Results were presented to a multidisciplinary expert panel (n = 13) to identify opportunities for improvement. RESULTS: Deductively coded themes included composition and functioning of the MAC, education and information needs and support to better manage polypharmacy. Emergent inductively coded themes included general medical practitioner (GP) and pharmacist engagement, collaboration and effectiveness. Participation by GPs and pharmacists was variable, while no MACs involved residents or family carers. Aged care specific and multidisciplinary MACs were generally more proactive in addressing potential medication-related harm. Education to identify and report adverse drug events with high risk medications was identified as a priority. The multidisciplinary panel made 12 recommendations to promote safe and effective medication use. CONCLUSION: Despite all MACs having a strong commitment to medication safety, opportunities exist to improve the composition and structure, proactive identification and response to emerging issues, and systems for staff, resident and family carer training.

Cost-Effectiveness of Pharmacist-Led Deprescribing of NSAIDs in Community-Dwelling Older Adults.

OBJECTIVES: Older adults are often prescribed potentially inappropriate medications associated with adverse health outcomes and increased health services utilization. Developing Pharmacist-led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly (D-PRESCRIBE), a pragmatic randomized clinical trial, demonstrated how a community pharmacist-led evidence-based educational intervention successfully empowered community-dwelling older adults and their physicians to reduce chronic use of inappropriate medications. The objective of this study was to evaluate the cost-effectiveness of the D-PRESCRIBE intervention for discontinuing nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Cost-effectiveness analysis. SETTING: Canada. PARTICIPANTS: Community-dwelling adults aged 65 years and older. MEASUREMENTS: Decision analysis combining decision tree and Markov state transition modeling was developed to estimate the cost-effectiveness of D-PRESCRIBE (NSAIDs) compared with usual care from a Canadian healthcare system perspective with a time horizon of 1 year. Data from the D-PRESCRIBE trial and published literature were used to calculate effectiveness, utilities, and costs. Reference case and scenario analyses were conducted using probabilistic modeling. Sensitivity analyses assessed the robustness of the reference case model. RESULTS: D-PRESCRIBE (NSAIDs) was less costly (-$1008.61) and more effective (.11 quality-adjusted life-years [QALYs]) than usual care and was the dominant strategy. At willingness-to-pay thresholds of $50 000 per QALY and $100 000 per QALY, D-PRESCRIBE (NSAIDs) incurred a positive incremental net benefit compared with usual care, suggesting it is cost-effective. Compared with the reference case, scenario analyses gave comparable QALYs with modest variation in cost estimates. CONCLUSION: For community-dwelling older adults, D-PRESCRIBE (NSAIDs) provides greater benefits at lower system costs, making it a compelling strategy to reduce the use and harms associated with chronic NSAID consumption. Our findings support reimbursing community pharmacists' clinical professional services for deprescribing inappropriate NSAIDs in community-dwelling older adults. J Am Geriatr Soc 68:1090-1097, 2020.