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

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

Background: A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. Methods: A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. Findings: A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with ‘quick wins’, offering deprescribing as ‘drug holidays’, and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. Conclusion: We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

Deprescribing, Medicines optimisation, Multidisciplinary team, Older people, Polypharmacy, Primary care, Realist review
1471-2318
Radcliffe, Eloise
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Servin, Renee
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Cox, Natalie
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Lim, Stephen
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Tan, Qian Yue
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Howard, Clare
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Sheikh, Claire J.
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Rutter, Paul
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Latter, Sue
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Lown, Mark
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Brad, Lawrence
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Fraser, Simon D.S.
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Bradbury, Katherine
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Roberts, Helen C.
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Recio Saucedo, Alejandra
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Ibrahim, Kinda
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Radcliffe, Eloise
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Servin, Renee
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Cox, Natalie
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Lim, Stephen
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Tan, Qian Yue
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Howard, Clare
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Sheikh, Claire J.
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Rutter, Paul
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Latter, Sue
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Lown, Mark
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Brad, Lawrence
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Fraser, Simon D.S.
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Bradbury, Katherine
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Roberts, Helen C.
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Recio Saucedo, Alejandra
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Ibrahim, Kinda
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Radcliffe, Eloise, Servin, Renee, Cox, Natalie, Lim, Stephen, Tan, Qian Yue, Howard, Clare, Sheikh, Claire J., Rutter, Paul, Latter, Sue, Lown, Mark, Brad, Lawrence, Fraser, Simon D.S., Bradbury, Katherine, Roberts, Helen C., Recio Saucedo, Alejandra and Ibrahim, Kinda (2023) What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC Geriatrics, 23 (591), [591]. (doi:10.1186/s12877-023-04256-8).

Record type: Article

Abstract

Background: A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. Methods: A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. Findings: A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with ‘quick wins’, offering deprescribing as ‘drug holidays’, and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. Conclusion: We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

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V2 MODIFY Realist review 30.6.23 - Accepted Manuscript
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Accepted/In Press date: 25 August 2023
Published date: 25 September 2023
Additional Information: Funding Information: Stephen Lim is funded by the National Institute for Health Research Advanced Fellowship. Funding Information: Qian Yue Tan is funded by the National Institute for Health Research Applied Research Collaboration Wessex. Publisher Copyright: © 2023, BioMed Central Ltd., part of Springer Nature. © 2023. The Author(s).
Keywords: Deprescribing, Medicines optimisation, Multidisciplinary team, Older people, Polypharmacy, Primary care, Realist review

Identifiers

Local EPrints ID: 481858
URI: http://eprints.soton.ac.uk/id/eprint/481858
ISSN: 1471-2318
PURE UUID: 8233cd67-aa1c-487d-947d-fbe331fb0d6e
ORCID for Natalie Cox: ORCID iD orcid.org/0000-0002-4297-1206
ORCID for Stephen Lim: ORCID iD orcid.org/0000-0003-2496-2362
ORCID for Sue Latter: ORCID iD orcid.org/0000-0003-0973-0512
ORCID for Mark Lown: ORCID iD orcid.org/0000-0001-8309-568X
ORCID for Simon D.S. Fraser: ORCID iD orcid.org/0000-0002-4172-4406
ORCID for Katherine Bradbury: ORCID iD orcid.org/0000-0001-5513-7571
ORCID for Helen C. Roberts: ORCID iD orcid.org/0000-0002-5291-1880
ORCID for Alejandra Recio Saucedo: ORCID iD orcid.org/0000-0003-2823-4573
ORCID for Kinda Ibrahim: ORCID iD orcid.org/0000-0001-5709-3867

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Date deposited: 11 Sep 2023 17:06
Last modified: 05 Oct 2024 02:16

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Contributors

Author: Renee Servin
Author: Natalie Cox ORCID iD
Author: Stephen Lim ORCID iD
Author: Qian Yue Tan
Author: Clare Howard
Author: Claire J. Sheikh
Author: Paul Rutter
Author: Sue Latter ORCID iD
Author: Mark Lown ORCID iD
Author: Lawrence Brad
Author: Kinda Ibrahim ORCID iD

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