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Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older AdultsThe D-PRESCRIBE Randomized Clinical Trial

Educational Objective
To learn about deprescribing interventions.
1 Credit CME
Key Points

Question  Can a consumer-targeted, pharmacist-led educational intervention reduce prescriptions for inappropriate medication among community-dwelling older adults?

Findings  In this cluster randomized trial that included 489 older adults, the percentage achieving discontinuation of a targeted inappropriate prescription at 6 months was 43% among patients receiving the intervention vs 12% receiving usual care, which represents a significant difference.

Meaning  A pharmacist-led intervention has the potential to reduce prescriptions for inappropriate medication in older adults.


Importance  High rates of inappropriate prescribing persist among older adults in many outpatient settings, increasing the risk of adverse drug events and drug-related hospitalizations.

Objective  To compare the effectiveness of a consumer-targeted, pharmacist-led educational intervention vs usual care on discontinuation of inappropriate medication among community-dwelling older adults.

Design, Setting, and Participants  A cluster randomized trial (D-PRESCRIBE [Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly]) that recruited community pharmacies in Quebec, Canada, from February 2014 to September 2017, with follow-up until February 2018, and randomly allocated them to intervention or control groups. Patients included were adults aged 65 years and older who were prescribed 1 of 4 Beers Criteria medications (sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs), recruited from 69 community pharmacies. Patients were screened and enrolled before randomization.

Interventions  Pharmacists in the intervention group were encouraged to send patients an educational deprescribing brochure in parallel to sending their physicians an evidence-based pharmaceutical opinion to recommend deprescribing. The pharmacists in the control group provided usual care. Randomization occurred at the pharmacy level, with 34 pharmacies randomized to the intervention group (248 patients) and 35 to the control group (241 patients). Patients, physicians, pharmacists, and evaluators were blinded to outcome assessment.

Main Outcomes and Measures  Discontinuation of prescriptions for inappropriate medication at 6 months, ascertained by pharmacy medication renewal profiles.

Results  Among 489 patients (mean age, 75 years; 66% women), 437 (89%) completed the trial (219 [88%] in the intervention group vs 218 [91%] in the control group). At 6 months, 106 of 248 patients (43%) in the intervention group no longer filled prescriptions for inappropriate medication compared with 29 of 241 (12%) in the control group (risk difference, 31% [95% CI, 23% to 38%]). In the intervention vs control group, discontinuation of inappropriate medication occurred among 63 of 146 sedative-hypnotic drug users (43.2%) vs 14 of 155 (9.0%), respectively (risk difference, 34% [95% CI, 25% to 43%]); 19 of 62 glyburide users (30.6%) vs 8 of 58 (13.8%), respectively (risk difference, 17% [95% CI, 2% to 31%]); and 19 of 33 nonsteroidal anti-inflammatory drug users (57.6%) vs 5 of 23 (21.7%), respectively (risk difference, 35% [95% CI, 10% to 55%]) (P for interaction = .09). Analysis of the antihistamine drug class was not possible because of the small sample size (n = 12). No adverse events requiring hospitalization were reported, although 29 of 77 patients (38%) who attempted to taper sedative-hypnotics reported withdrawal symptoms.

Conclusions and Relevance  Among older adults in Quebec, a pharmacist-led educational intervention compared with usual care resulted in greater discontinuation of prescriptions for inappropriate medication after 6 months. The generalizability of these findings to other settings requires further research.

Trial Registration  ClinicalTrials.gov Identifier: NCT02053194

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Article Information

Accepted for Publication: September 25, 2018.

Corresponding Author: Cara Tannenbaum, MD, MSc, Centre de Recherche de l’Institut universitaire de gériatrie de Montréal, 4545 Queen Mary Rd, Montreal, QC, Canada H3W 1W5 (cara.tannenbaum@umontreal.ca).

Author Contributions: Dr Martin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Martin, Ahmed, Tannenbaum.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Martin, Tannenbaum.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Martin, Benedetti, Ahmed.

Obtained funding: Martin, Tannenbaum.

Administrative, technical, or material support: Martin.

Supervision: Martin.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Martin received a bursary from the Michel Saucier Endowed Chair in Pharmacology, Health and Aging of the Faculty of Pharmacy of the Université de Montréal. Drs Ahmed and Tannenbaum are clinician-scientists funded by the Fonds de Recherche en Santé de Quebec. No other disclosures were reported.

Funding/Support: This study was funded by Canadian Institutes of Health Research Grant CIHR 201303MOP-299872-KTR.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We wish to acknowledge Isabelle Reid, MSc, who coordinated and conducted the in-home interviews, enrolled patients in the study, and helped with database management. We also thank Danielle Clément,BA; Liliane Cefaloni, BA; Marie-Ève Lavoie, PhD; and Céline Morisette, PhD, who aided with recruitment and follow-up. Isabelle Reid, MSc; Danielle Clément, BA; Liliane Cefaloni, BA; Marie-Ève Lavoie, PhD; and Céline Morisette, PhD, were all affiliated with the Centre de recherche de l'Institut universitaire de gériatrie de Montréal. Nancy Zhang (PharmD student) provided assistance with the pharmaceutical profiles and is affiliated with the Université de Montréal. All of the above-mentioned individuals received financial compensation for their contribution to this work. Alex Halme, MD, PharmD, of McGill University provided assistance without compensation for the multivariable imputation modeling. We express gratitude to all the patients and pharmacists who took part in this trial. Telus, the Pharmaprix, Uniprix, and Brunet pharmacy chains were instrumental as collaborators.

Patel  R, Zhu  L, Sohal  D,  et al.  Use of 2015 Beers Criteria medications by older Medicare beneficiaries.  Consult Pharm. 2018;33(1):48-54. doi:10.4140/TCP.n.2018.48PubMedGoogle ScholarCrossref
Canadian Institute for Health Information.  Drug Use Among Seniors in Canada, 2016. Ottawa, ON: Canadian Institute for Health Information; 2018. https://www.cihi.ca/sites/default/files/document/drug-use-among-seniors-2016-en-web.pdf. Accessed September 14, 2018.
The American Geriatrics Society 2015 Beers Criteria Update Expert Panel.  American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults.  J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702PubMedGoogle ScholarCrossref
Budnitz  DS, Lovegrove  MC, Shehab  N, Richards  CL.  Emergency hospitalizations for adverse drug events in older Americans.  N Engl J Med. 2011;365(21):2002-2012. doi:10.1056/NEJMsa1103053PubMedGoogle ScholarCrossref
Scott  IA, Hilmer  SN, Reeve  E,  et al.  Reducing inappropriate polypharmacy: the process of deprescribing.  JAMA Intern Med. 2015;175(5):827-834. doi:10.1001/jamainternmed.2015.0324PubMedGoogle ScholarCrossref
Anderson  K, Stowasser  D, Freeman  C, Scott  I.  Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.  BMJ Open. 2014;4(12):e006544. doi:10.1136/bmjopen-2014-006544PubMedGoogle ScholarCrossref
Sussman  JB, Kerr  EA, Saini  SD,  et al.  Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus.  JAMA Intern Med. 2015;175(12):1942-1949. doi:10.1001/jamainternmed.2015.5110PubMedGoogle ScholarCrossref
Spinewine  A, Fialová  D, Byrne  S.  The role of the pharmacist in optimizing pharmacotherapy in older people.  Drugs Aging. 2012;29(6):495-510. doi:10.2165/11631720-000000000-00000PubMedGoogle ScholarCrossref
Tannenbaum  C, Tsuyuki  RT.  The expanding scope of pharmacists' practice: implications for physicians.  CMAJ. 2013;185(14):1228-1232. doi:10.1503/cmaj.121990PubMedGoogle ScholarCrossref
Krska  J, Cromarty  JA, Arris  F,  et al.  Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care.  Age Ageing. 2001;30(3):205-211. doi:10.1093/ageing/30.3.205PubMedGoogle ScholarCrossref
Kaur  S, Mitchell  G, Vitetta  L, Roberts  MS.  Interventions that can reduce inappropriate prescribing in the elderly: a systematic review.  Drugs Aging. 2009;26(12):1013-1028. doi:10.2165/11318890-000000000-00000PubMedGoogle ScholarCrossref
Avery  AJ, Rodgers  S, Cantrill  JA,  et al.  A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.  Lancet. 2012;379(9823):1310-1319. doi:10.1016/S0140-6736(11)61817-5PubMedGoogle ScholarCrossref
Tannenbaum  C, Martin  P, Tamblyn  R, Benedetti  A, Ahmed  S.  Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial.  JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949PubMedGoogle ScholarCrossref
Martin  P, Tannenbaum  C.  A realist evaluation of patients’ decisions to deprescribe in the EMPOWER trial.  BMJ Open. 2017;7(4):e015959. doi:10.1136/bmjopen-2017-015959PubMedGoogle ScholarCrossref
Zhang  YZ, Turner  JP, Martin  P, Tannenbaum  C.  Does a consumer-targeted deprescribing intervention compromise patient-healthcare provider trust?  Pharmacy (Basel). 2018;6(2):31. doi:10.3390/pharmacy6020031PubMedGoogle ScholarCrossref
Martin  P, Tamblyn  R, Ahmed  S, Benedetti  A, Tannenbaum  C.  A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial.  Trials. 2015;16:266. doi:10.1186/s13063-015-0791-1PubMedGoogle ScholarCrossref
Cockrell  JR, Folstein  MF.  Mini-Mental State Examination (MMSE).  Psychopharmacol Bull. 1988;24(4):689-692.PubMedGoogle Scholar
Ware  J  Jr, Kosinski  M, Keller  SDA.  A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.  Med Care. 1996;34(3):220-233. doi:10.1097/00005650-199603000-00003PubMedGoogle ScholarCrossref
Saliba  D, Elliott  M, Rubenstein  LZ,  et al.  The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community.  J Am Geriatr Soc. 2001;49(12):1691-1699. doi:10.1046/j.1532-5415.2001.49281.xPubMedGoogle ScholarCrossref
Martin  P, Tamblyn  R, Ahmed  S, Tannenbaum  C.  An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial.  Trials. 2013;14:80. doi:10.1186/1745-6215-14-80PubMedGoogle ScholarCrossref
Martin  P, Tannenbaum  C. A prototype for evidence-based pharmaceutical opinions to promote physician-pharmacist communication around deprescribing.  Can Pharm J (Ott). 2018;151(2):133-141.PubMedGoogle ScholarCrossref
Canadian Pharmacists Association.  A review of pharmacy services in Canada and the health and economic evidence. Ottawa, ON: Canadian Pharmacists Association; 2016. https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Pharmacy%20Services%20Report%201.pdf.
Eldridge  SM, Ashby  D, Kerry  S.  Sample size for cluster randomized trials: effect of coefficient of variation of cluster size and analysis method.  Int J Epidemiol. 2006;35(5):1292-1300. doi:10.1093/ije/dyl129PubMedGoogle ScholarCrossref
Dupont  WD, Plummer  WD  Jr.  Power and sample size calculations. A review and computer program.  Control Clin Trials. 1990;11(2):116-128. doi:10.1016/0197-2456(90)90005-MPubMedGoogle ScholarCrossref
Ukoumunne  OC, Forbes  AB, Carlin  JB, Gulliford  MC.  Comparison of the risk difference, risk ratio and odds ratio scales for quantifying the unadjusted intervention effect in cluster randomized trials.  Stat Med. 2008;27(25):5143-5155. doi:10.1002/sim.3359PubMedGoogle ScholarCrossref
McAlister  FA, Straus  SE, Guyatt  GH, Haynes  RB; Evidence-Based Medicine Working Group.  Users’ guides to the medical literature, XX: integrating research evidence with the care of the individual patient.  JAMA. 2000;283(21):2829-2836. doi:10.1001/jama.283.21.2829PubMedGoogle ScholarCrossref
Tamblyn  R, Eguale  T, Buckeridge  DL,  et al.  The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial.  J Am Med Inform Assoc. 2012;19(4):635-643. doi:10.1136/amiajnl-2011-000609PubMedGoogle ScholarCrossref
Monane  M, Matthias  DM, Nagle  BA, Kelly  MA.  Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer.  JAMA. 1998;280(14):1249-1252. doi:10.1001/jama.280.14.1249PubMedGoogle ScholarCrossref
Hanlon  JT, Weinberger  M, Samsa  GP,  et al.  A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.  Am J Med. 1996;100(4):428-437. doi:10.1016/S0002-9343(97)89519-8PubMedGoogle ScholarCrossref
Curran  HV, Collins  R, Fletcher  S, Kee  SC, Woods  B, Iliffe  S.  Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life.  Psychol Med. 2003;33(7):1223-1237. doi:10.1017/S0033291703008213PubMedGoogle ScholarCrossref
Allard  J, Hebert  R, Rioux  M, Asselin  J, Voyer  L.  Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people.  CMAJ. 2001;164(9):1291-1296.PubMedGoogle Scholar
Canadian Foundation for Pharmacy. Changing face of pharmacy. Fees and claims data for government-sponsored pharmacist services, by province (updated September 2017). Mississauga. https://www.cfpnet.ca/bank/document_en/118-2017-changing-face-of-pharmacy.pdf. 2017 Accessed September 11, 2018.
American Pharmacists Association. Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing. Washington, DC: American Pharmacists Association; 2018.
Rat  C, Penhouet  G, Gaultier  A,  et al.  Did the new French pay-for-performance system modify benzodiazepine prescribing practices?  BMC Health Serv Res. 2014;14(1):301. doi:10.1186/1472-6963-14-301PubMedGoogle ScholarCrossref
Schnipper  JL, Rothschild  JM.  Improving medication safety.  Lancet. 2012;379(9823):1278-1280. doi:10.1016/S0140-6736(12)60078-6PubMedGoogle ScholarCrossref
Committee  CDACPGE.  Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada.  Can J Diabetes. 2013;37(suppl 1):s1-s212.PubMedGoogle Scholar
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