Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial

Abstract

Objectives: Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.

Design: Pragmatic multicenter stepped-wedge cluster randomized controlled trial.

Setting and participants: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.

Methods: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.

Results: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians.

Conclusions and implications: Multidisciplinary medication review-directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.

Keywords: Deprescribing; falls; hospitalization; mortality; older adults; polypharmacy.