Development Of The Physician-pharmacist Partnership Intervention To Deprescribe Medications (pppi-dm) And Its Feasibility In Primary Care

• By: GOH, Sheron Sir Loon (Universiti Malaya, Malaysia)
• Co-author(s): Dr Sheron Sir Loon Goh (Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia)
  Prof Pauline Lai (Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia)
  Dr Siti Nurkamilla Ramdzan (Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia)
  Associate Professor Kit Mun Tan (Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia)
  
• Abstract:

  Background information:
  Deprescribing is a systematic process of withdrawing potentially inappropriate medications (PIMs) to minimise polypharmacy and improve patient outcomes. Previous studies in developed countries found that deprescribing interventions which involved pharmacists have been effective in reducing PIMs. To date, there is limited data on deprescribing interventions for older persons in upper- and middle-income countries like Malaysia.
  
  Purpose: To develop and evaluate the feasibility of the Physician-Pharmacist Partnership Intervention to Deprescribe Medications (PPPi-DM) among ambulatory older persons in a primary care clinic in Malaysia.
  
  Methods: The PPPi-DM was developed based on findings from a qualitative study, which reported that doctors preferred a step-by-step deprescribing intervention that included pharmacists to review patients’ medications. This led to the development of the PPi-DM. We modified the physician-pharmacist-partnership for patient safety (PPP-PS) intervention, which was initially developed in our setting to identify drug-related problems in patients. This intervention consists of five steps: 1)obtaining a comprehensive medication history, 2)identifying any PIMs, 3)determining whether medication can be ceased and prioritised, 4)planning and initiating medication withdrawal and 5)monitoring, support and documentation. The feasibility of PPi-DM was then conducted in March 2022. Older patients (≥65 years) with multiple chronic diseases, prescribed ≥5 medications and having ≥1 PIMs (according to Beer's Criteria 2019) were recruited. Primary care trainees (defined as doctors who were undergoing their 4-year specialist training in family medicine) who were treating these patients were also recruited. Outcomes measured were the proportion of PIMs identified and deprescribed, doctors’ acceptance rate regarding pharmacist’s recommendations and the process of delivering the intervention in a feasibility study.
  
  Results: 20/35 (response rate=57.1%) patients and 14/14 doctors (response rate=100%) were recruited. A total of 36/167 (22%) PIMs were identified from 20 patients; 34/36 (94%) PIMs were identified by the pharmacist and 2/36 (6%) were identified by doctors. Deprescribing was performed on 14/20 (70%) older patients. The number of PIMs accepted for deprescribing was 19/36 (52.7%). A total of 17/34 (50%) PIMs proposed by the pharmacist and 2/2 (100%) by doctors were deprescribed. Minimal issues were encountered during the process of delivering this intervention. The eligibility criteria used for recruitment and the current workflow used for deprescribing medications were suitable. Both patients and doctors were able to understand and complete all procedures. The total time taken for one patient to complete the entire process ranged from 45-60 minutes. The pharmacist was able to perform medication reviews in a designated room in the clinic and experienced no problems with documentation using predesigned forms. Patients and doctors were receptive to the idea of deprescribing. All patients agreed to deprescribe their medication when suggested by their doctor. Some doctors did not deprescribe medication(s) as it was still indicated 15/17 (88.2%), did not want to interfere with medications prescribed by another specialist 1/15 (6.7%), and insufficient time during the patient-doctor consultation 1/15 (6.7%).
  
  Conclusion: The PPPi-DM was successfully developed and was found to be feasible in our setting. A randomised controlled trial should be conducted to assess the effectiveness of PPPi-DM in improving clinical outcomes.