What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis

Problem

A third of older people (aged 65 and over) take five or more regular medications (polypharmacy). This potentially increases the risk of side-effects, hospital admission and death, with higher risk among people living with frailty. Conducting regular structured medication reviews in primary care is key to identify and reduce or stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach for medication review. Our aims were to identify the mechanisms and context that could lead to a successful multidisciplinary medication review/deprescribing process in primary care, and to identify the role of different healthcare professionals in the process and any training needs.

Approach

A realist review and synthesis was conducted to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDT) work (or do not work) for older people. The Realist review was conducted following the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines. An initial scoping review of the literature informed the generation of initial programme theories, which were further developed in consultation with stakeholders, including 23 health care professionals working in primary care, 9 patients and 2 informal carers. Our search strategy, based on a Context, Mechanisms, Outcome (CMO) question framework was completed on Medline, EMBASE, CINAHL, Pubmed, Web of Science, PsycINFO and Cochrane Library, supplemented with citation tracking and grey literature searches (via google and google scholar). The quality of included documents was appraised based on assessments of relevance and rigour.

Findings

A total of 2821 abstracts and then 175 full-text articles were assessed for eligibility. A total of 26 documents were included. The analysis outlined 34 context-mechanism-outcome configurations categorised under four overarching themes: 1) healthcare professional (HCP) roles, responsibilities and relationships; 2) healthcare professional training and education; 3) the format and process of the medication review with three subthemes (efficiency of the multidisciplinary process, mode of communication and patient follow-up); 4) involvement and education of patients and informal carers. Different mechanisms have been identified that could potentially enhance implementation of MDT medication review. This includes integration of pharmacists, offering deprescribing as a trial off medication, taking into account patients’ preferences and priorities, addressing patients’ worries by starting with the ‘quick wins’, using deprescribing tools, prioritising and targeting high-risk patients, involving and using the expertise of other HCPs such as nurses and frailty practitioners.

Consequences

Our work highlights the complexity of deprescribing interventions and identified a number of mechanisms to support uptake and implementation of deprescribing recommendations. These findings could potentially support general practices to prioritise and implement deprescribing more efficiently, drawing on the expertise of the team members.