Deprescribing – reactive and proactive

“Deprescribing is often thought of as a homogenous behaviour ……. but in 2018 we defined two distinct behaviours – …. ‘reactive’ and ‘proactive’ deprescribing”, says Professor Bhattacharya.  Reactive deprescribing is when a medicine is stopped in response to a clinical trigger, whereas proactive deprescribing is when a medicine is stopped because the risk of future harm outweighs the likelihood of future benefit.

“So, it’s a much more complex decision that absolutely has to be made in partnership with a patient”, she emphasises.

Clinical guidelines emphasise situations when medicines should be started but not when or how to stop medicines, she comments.

Barriers and enablers for deprescribing

“There are there are numerous barriers and enablers – things that will help practitioners and patients to proactively stop a medicine but …. there’s no one-size-fits all”, says Professor Bhattacharya. Understanding the factors that operate in any given situation is essential if effective interventions are to be devised. For example, in one hospital project, both patients and pharmacists felt that doctors should initiate the deprescribing discussion. In contrast, an opioid deprescribing project in primary care is being largely led by pharmacists, who are also initiating the deprescribing discussions.

It is a common misconception that patients are resistant to having their medicine stopped proactively, although when deprescribing interventions have been offered to patients in trials, in the majority of cases they’ve been rejected by the patient. Having sufficient time and skill to discuss the issues in a meaningful way may be the key to success here.

CHARMER – a different kind of deprescribing intervention study

Many previous studies of proactive deprescribing interventions have failed to demonstrate positive outcomes. The CHARMER study – Comprehensive geriatrician-led medication review – has developed a new approach.  Five critical factors identified by prescribers and patients as being key to success, have been built into the study. They are:

1. Ensuring that practitioners feel that deprescribing is a priority for their employer
2. Addressing the misconception that patients are resistant to deprescribing
3. Overcoming the feeling amongst pharmacists that it is safer to do nothing rather than to stop a medicine that’s currently causing no harm, even though it is likely that in the future it will cause harm
4. Provision of protected time for pharmacists and geriatricians to meet to discuss patients that may benefit from deprescribing
5. Provision of feedback so that practitioners see the results of their efforts.

The CHARMER study will involve 24 hospitals in England and will be completed in 2025.

About Professor Debi Bhattacharya

Professor Bhattacharya leads a research team that focuses on applying behaviour change methods to improve health outcomes.  The team works with a wide range of funding bodies and organisations to design and implement behaviour change strategies for patients and healthcare professionals. In addition, she is the director of Leicester’s independent prescribing course for pharmacists.

Read and watch the full series on our website or on YouTube.

Many previous studies of proactive deprescribing interventions have failed to demonstrate positive outcomes. Bearing this in mind, CHARMER – Comprehensive geriatrician-led medication review – has developed a new approach.

Professor Bhattacharya says: “The intervention has taken us seven years of development. We started right from the beginning – understanding what patients, geriatricians and pharmacists feel about proactive deprescribing – what are the barriers? what are the enablers? – and then we’ve designed an intervention that specifically targets the things that they prioritised as needing addressing. For example, when we spoke to geriatricians and pharmacists, they said they felt very confident in their knowledge to be able to identify when medicine should be considered for stopping. So, unlike other interventions, we’re not providing any education or …. lists of medicines that should be considered for stopping. They actually said that would put them off”.

Electronic prompts and alerts have also been excluded as practitioners frequently complain of ‘prompt fatigue’.  They say, ‘You know, we’re constantly getting those for everything – it’s just yet another one for us to ignore’.

Five key elements emerged from the background work that Professor Bhattacharya’s team undertook and these had to be built into the CHARMER protocol. They were:

1. Ensure that practitioners feel that deprescribing is a priority for their employer
2. Address the misconception that patients are resistant to deprescribing
3. Overcome the feeling amongst pharmacists that it was safer to do nothing rather than to stop a medicine that’s currently causing no harm, even though it is likely that in the future it will cause harm
4. Provide protected time for pharmacists to meet with geriatricians to discuss patients that may benefit from deprescribing
5. Incorporate feedback so that practitioners see the results of their efforts.

The feedback scheme was co-designed with practitioners. When they have a discussion with a patient about proactive deprescribing and the patient agrees to try a discontinuation of a medicine, the details are entered into a computerised record. “That data then gets fed into a system that then reports back to them. They can see not just their performance as a hospital but the performance of all the other hospitals in the trial – and that, they said, was the best that they felt we could do in terms of them seeing some kind of positive outcome from their extra efforts”, says Professor Bhattacharya.

Small-scale testing of the CHARMER intervention in four hospitals has been completed and the main trial, which will be across 24 hospitals in England, is scheduled to start in the Autumn of this year (2023). The trial should finish in 2025 and the first results are expected in early 2026.

Read and watch the full series on our website or on YouTube.

“There are there are numerous barriers and enablers – things that will help practitioners and patients to proactively stop a medicine and what we need to do is to design strategies that address these barriers and the enablers. …. There’s no one-size-fits all”, says Professor Bhattacharya.  The barriers and enablers are often context-specific. For example, an opioid deprescribing project in an Integrated Care Service (ICS) is very different from deprescribing for older people in a hospital setting.  The research community needs to understand the key barriers and enablers in different contexts and then harness behavioural science to address proactive deprescribing, she says.

Who should lead deprescribing?

“In 2018 we surveyed 150 Hospital inpatients and their family members; they said that they wanted the deprescribing discussion to be initiated by a doctor. When we spoke to hospital pharmacists, they also said that they would prefer that the discussion was initiated by the doctor and that they were happy to identify medicines that might require stopping”, she says.  In contrast, an opioid deprescribing project in primary care is being largely led by pharmacists, who are also initiating the deprescribing discussions.

Many prescribers harbour “a misconception that patients are resistant or will be resistant to proactively having their medicine stopped and that is a significant barrier to pharmacists, geriatricians [and] doctors across the board initiating deprescribing discussions. So, we know that this is a misconception because when we surveyed 150 people they actually said, “We’re horrified that that you would keep us on medicines that that might not be the right thing for us” – so there is definitely an appetite for medicines to be stopped where the chance of harm outweighs benefit”, she says.  However, when deprescribing interventions have been offered to patients in trials, in the majority of cases they’ve been rejected by the patient. “So, there is that disconnect between patients saying, ‘Actually we want to make sure that we’re only on the right medicines’ versus when they’re asked would they would they like to consider stopping, they opt not to”, she adds.

The results of a recent international survey of pharmacists, doctors and nurses involved in proactive deprescribing of medicines showed that one of the key challenges to proactive deprescribing was not having the time to have a meaningful discussion with the patient.

Typically, such discussions would bring together information about the patient’s goals and priorities and the clinical information about the balance of risks and benefits of the treatment in order to support the patient in making a decision. Practitioners reported that they did not have the time to do this and did not always have the skills to navigate that discussion. “So that may shed some light on this disconnect between patients absolutely wanting to only be on medicines where the chance of benefit outweighs harm versus being resistant to medicines being stopped when it’s proposed by a member of the healthcare team, she says.

Read and watch the full series on our website or on YouTube.

Professor Bhattacharya leads a research team that focuses on applying behaviour change methods to improve health outcomes.  The team works with a wide range of funding bodies and organisations to design and implement behaviour change strategies for patients and healthcare professionals. In addition, she is the director of Leicester’s independent prescribing course for pharmacists.

“Deprescribing is often thought of as a homogenous behaviour ……. but in 2018 we defined two distinct behaviours – …. ‘reactive’ and ‘proactive’ deprescribing”, she says.  Reactive deprescribing is when a medicine is stopped in response to a clinical trigger, for example, stopping an ACE-inhibitor in response to acute kidney injury because the ACE-inhibitor will make that worse. This behaviour requires limited clinical decision making and also limited patient involvement because the action needs to be taken to prevent further harm, she explains. On the other hand, proactive deprescribing requires evaluation of the likelihood of future benefit versus future harm. “So, it’s a much more complex decision that absolutely has to be made in partnership with a patient”, she emphasises.

The need for deprescribing

“No-one sets out to prescribe a medicine that does more harm than good but what happens often is the balance of benefit and harm changes” as an individual ages, explains Professor Bhattacharya. For example, antihypertensive medication started in someone’s 40s may no longer be necessary when they reach their 80s and may even be harmful. It could increase the risk of dizziness and lead to a fall. Deprescribing in such circumstances, to prevent future harm, sounds straightforward but there are challenges, she cautions. An international survey of practitioners showed that “we’ve often introduced medicines to patients as being for life and so suddenly stopping them, particularly later in someone’s life, can be quite alarming for them. You know, ……. a feeling that we’re de-investing in them rather than making a positive decision to improve their quality of life”, she explains. “It’s definitely a much more difficult thing to do”, she adds.

In addition, according to focus groups held with NHS Hospital doctors and pharmacists, prescribing pathways, such as those produced by The National Institute for Health and Care Excellence (NICE), emphasise situations when medicines should be started but not when or how to stop medicines.

It is also important to involve the patient in decision-making because it involves balancing of patient priorities with prescribing guidelines and clinical judgment. This all takes time which is a significant challenge to describing, she acknowledges.

Read and watch the full series on our website or on YouTube.