Optimising a whole-person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy: the TAILOR Medication Synthesis

Reeve, Joanne, Maden, Michelle ORCID: 0000-0003-4419-6343, Hill, Ruaraidh ORCID: 0000-0002-2801-0505, Turk, Amadea, Mahtani, Kamal, Wong, Geoff, Lasserson, Dan, Krska, Janet, Mangin, Dee, Byng, Richard
et al (show 2 more authors) (2022) Optimising a whole-person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy: the TAILOR Medication Synthesis. Health Technology Assessment.

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Background: Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing); but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help us understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. Objectives: We identified two research questions. 1) What evidence exists to support the safe, effective and acceptable stopping of medication in this patient group? 2) How, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: a) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; b) to undertake a realist synthesis review to construct a programme theory that describes ‘best practice’ and helps explain the heterogeneity of deprescribing approaches; and c) to translate findings into resources to support tailored prescribing in clinical practice. Data sources: Experienced information specialists conducted comprehensive searches in MEDLINE, CINAHL, Web of Science, EMBASE, The Cochrane Library (CDSR, CENTRAL), Joanna Briggs Database of Systematic Reviews and Implementation Reports, Google and Google Scholar (targeted searches). Review methods: The scoping review followed the five steps described by the Johanna Briggs Institute methodology for conducting a scoping review . The realist review followed the methodological and publication standards for realist reviews described by the RAMESES group. PPI partners ensured our analysis retained a patient-centred focus. Results: Our scoping review identified 9528 abstracts: 8847 removed at screening, 662 at full text review. Leaving 20 studies (published between 2009-2020) which examined the effectiveness, safety and acceptability of deprescribing in adults (≥50 years) with polypharmacy (≥5 prescribed medications) and multi-morbidity (≥2 conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians for the safety, clinician acceptability and potential effectiveness of clinical decision making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 references with 119 included in the final analysis. Analysis described 34 Context-Mechanism-Outcomes-Configurations describing the knowledge work of tailored prescribing under 8 headings related to organisational, healthcare provider and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations, and trust. Limitations: Scoping review - strict application of our definition of multimorbidity may have impacted on relevance to clinical practice. The realist review was limited by the data(evidence) available. Conclusions: Our combined reviews recognise deprescribing as a complex intervention; provide support for the safety of structured approaches to deprescribing; but highlight the need to integrate patient-centred and contextual factors into best-practice models. Future work: TAILOR has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. Study registrations: PROSPERO 2018 CRD42018107544; PROSPERO 2018 CRD42018104176 Study funding: NIHR HTA 17/69/02

Item Type: Article
Additional Information: Polypharmacy, Deprescribing, Multimorbidity
Uncontrolled Keywords: Deprescribing, Multimorbidity, Polypharmacy
Divisions: Faculty of Health and Life Sciences
Faculty of Health and Life Sciences > Institute of Population Health
Depositing User: Symplectic Admin
Date Deposited: 28 Jul 2022 14:10
Last Modified: 18 Jan 2023 21:06
Open Access URL: https://doi.org/10.3310/AAFO2475
URI: https://livrepository.liverpool.ac.uk/id/eprint/3151761