PROJECT PRESENTATION (in English)
Prescription of medications is a fundamental component of health care. However, inappropriate prescriptions and overuse of medications could increase the risk of negative health consequences. Benzodiazepine receptor agonists (BZRA), used in case of insomnia or anxiety, are likely to be prescribed inappropriately. BZRA use is not recommended for more than 4 weeks, particularly among older adults who may experience various adverse effects such as higher risks of falls, hip fractures and cognitive impairment. Despite the current guidelines, 52% of nursing home residents are prescribed a BZRA for longer than 4 weeks in 99% of cases.
Deprescription aims to address the global problem of medication overuse through the reduction of the doses or discontinuing one or more medication that are no longer necessary for the patient. Deprescribing BZRA in the elderly is therefore a solution to the inappropriate use and overuse of these medication.
About DI-PRESCRIBE…
The research project DI-PRESCRIBE aims to advance knowledge of Deprescribing Implementation to decrease medication overuse in older people and improve health and quality of life. Specifically, the case of BZRA deprescribing will be investigated.
Some ground-breaking aspects of DI-PRESCRIBE are that it will consider:
All three levels of the health care system: patient/caregiver level, health care professionals’ level, and the organization/environment (i.e., system/policy) level
All three settings of care: ambulatory care, acute care, and long-term care
This research project also aims to address the current limitations in the literature according to which implementation science should be used to increase the translation of deprescribing evidence into practice and policy. More specifically, implementation science provides a set of theories, models and frameworks to understand the reasons behind the success or failure of interventions, but also what could be done to improve their impact.
DI-PRESCRIBE has 4, highly connected, work packages (WPs). Main goals and research methods of each of these WPs are introduced hereafter.
As part of the WP1, we plan to develop, implement and evaluate deprescribing theory-based interventions in clinical practice, in three settings of care (i.e., ambulatory, NH, acute care). This will be done to fill the gaps and weaknesses in deprescribing implementation research and address current limitations (i.e., limited use of theory, lack of standard terminology, heterogeneous measurement of outcomes, lack of process evaluation).
Especially, the development of these interventions will follow recent guidance and will proceed in four phases: developing intervention, assessing feasibility of the interventions and evaluation design in pilot trials, using case studies to refine hypotheses regarding context, mechanisms and outcomes within and across settings. Finally, a full evaluation in a hybrid effectiveness-implementation trial will be performed.
The research process of these interventions will also include stakeholders engagement as well as economic evaluation. Stakeholders engagement consists on collecting the point of views of patients’ and HCPs’ having a personal or professional interest for deprescription on the intervention. Economic evaluation aims at analysing the costs (i.e., resource use) and consequences (i.e., health outcomes) of an intervention. The adoption of a societal perspective will help to answer questions that matter most to decision-makers.
The second work package of this research project will explore how to enhance implementation of deprescription by investigating the determinants of patients’ and informal caregivers’ (i.e., spouses, adult children, etc.) willingness to engage in deprescription.
Current research findings indicate that positive and negative attitudes towards deprescribing often coexist. For instance, research found that among 11,049 participants, almost 88% of patients are willing to reduce their medication use following physician suggestions (ref). However, individuals may say they are open to deprescribing but also report high satisfaction with their medications. Hence, the available tools to assess patients’ willingness to stop their medication have difficulties to predict patients’ effective deprescribing. Current questionnaires thus probably do not capture all determinants of patients’ willingness to engage in deprescription.
To this end, a systematic review will be conducted in order to identify main determinants of patients’ and caregivers’ engagement in deprescription. Based on the results of this review, a questionnaire will be developed and administered for validation to a sample of patients and caregivers. Finally, a short version of this questionnaire will be developed to facilitate its administration in clinical practice.
The third work package aims to address the lack of knowledge on how to improve the competencies of future HCPs (i.e., physicians, nurses and pharmacists) for deprescription.
Indeed, current research findings showed that despite a high awareness of polypharmacy, final year medicine and pharmacy students have a low confidence in deprescribing without senior support, unclear views on professional roles and low self-efficacy in developing and implementing a deprescription plan. Despite the lack of studies investigating such topic, these preliminary findings highlight the necessary to improve teaching methods related to deprescribing for all health professionals.
For this purpose, barriers and enablers of deprescription will firstly be investigated through questionnaires and interviews. Precisely, questionnaires will investigate self-reported knowledge, skills and attitudes of students in medicine, pharmacy and nursing, whereas interviews will examine faculty members’ perceptions regarding the current teaching as well as barriers and enablers to teaching deprescribing. This will then be used to design, implement and evaluate an innovative educational approach.
The fourth work package will explore the policy landscape in relation to deprescribing for older people, that is, how national and regional policies can be leveraged to generate real practice change.
There are increasing efforts to introduce policies at the national or regional system levels to support deprescription in order to promote opportunities for deprescribing to take place while limiting the risk of unintended and negative consequences. However, studies investigating the implementation and outcomes of these policies remain scarce. A better understanding of how these approaches impact the implementation of deprescribing is thus required.
To this end, a rapid realist review will be performed on key policies that aimed to facilitate deprescribing for older people in Belgium, in the three settings of care (i.e., home, nursing home, and hospital). This will inform on plausible mechanisms that could explain why some policies work or not in Belgium. Following the identification of potential mechanisms, these will be discussed with policy makers and evaluated. Such process will help us to translate our results into key recommendations for both policymakers and stakeholders in order to increase implementation of deprescribing in clinical practice.