Feasibility study of a multidisciplinary DEprescribing review for Frail oldER Adults in Long-term care (DEFERAL) targeting potentially inappropriate antihypertensive medications
Authors: Heinrich C H , McCarthy S , McHugh S , Shanahan E R , Donovan M D 
Published: April 2024

Abstract

Introduction
Frail older adults who reside in long-term care facilities (LTCFs) are at a higher risk of adverse drug events due to potentially inappropriate medications (PIMs). Deprescribing is a safe and effective method of reducing PIMs. Despite the benefits, there is evidence that deprescribing is not being conducted. The DEFERAL strategy was designed to support healthcare professionals (HCPs) to deprescribe PIMs for frail older adults in LTCFs. DEFERAL consists of a three-monthly multi-disciplinary team (MDT) deprescribing review, incorporating evidence-based deprescribing tools. It is conducted in person at the LTCF, targeting one pre-determined class of PIMs, organised by a nurse champion on site.[1]

Aim
To test the DEFERAL strategy, focusing on implementation outcomes of acceptability, feasibility, appropriateness and fidelity while collecting intervention data on deprescribing decision-making.

Methods
A feasibility study was conducted, recruiting a convenience sample of two LTCFs in the South-West of Ireland. The LTCFs required a general practitioner, pharmacist and nurse to be eligible. To be included in the deprescribing review, patients were required to be ≥65 years, frail, prescribed ≥1 antihypertensive and to have no deprescribing contraindications. The study followed a hybrid type three design,[2] focusing on implementation outcomes whilst collecting intervention data. HCP feedback was collected using a post-meeting survey, which was emailed to HCPs or available in paper format via the on-site nurse champion. Data were analysed quantitatively. Open-ended comment boxes were analysed using content analysis. Data on intervention outcomes were collected using a summary sheet documenting meeting attendance, recruitment and decision-making, and were analysed quantitatively.

Results
The survey was completed by ten HCPs (83.3%). Of completed surveys, 100% (n=10) agreed that the DEFERAL strategy was acceptable and appropriate to support deprescribing and 90% (n=9) agreed that it was feasible to undertake. The majority (90%) of HCPs indicated that they completed their designated roles exactly as described; however, qualitative feedback described site-specific modifications. In Site 1, the wider MDT were not engaged as intended and the site did not facilitate the education and screening phase as described. Site 2 introduced an additional resource to facilitate documentation of clinical measurements to support deprescribing decision-making. From a total of 90 residents, 56 (62.2%) were prescribed ≥1 antihypertensive medication. Of those resident at the time of the review, 16 (29.6%) patients were eligible and deprescribing occurred for six patients (37.5%) through dose reduction of antihypertensive medications. Documented reasons for not deprescribing included fear of negative consequences and inappropriate blood pressure measurements.

Conclusion
The DEFERAL strategy led to successful deprescribing of antihypertensive medications in LTCFs, supported with positive feedback on implementation outcomes. A strength of the strategy is its universal nature. DEFERAL could be adjusted to support deprescribing for different PIMs, patient cohorts or organisational structures in LTC. The strategy provides a blueprint to support medication reviews in LTC, integrating the pharmacist into routine practice. Future research is required to test the strategy for effectiveness, considering the site-specific modifications. A study limitation was the lack of completion of the follow-up survey, limiting the completeness of the feedback on the strategy.

References
1. Heinrich CH, McHugh S, McCarthy S, Curran GM, Donovan MD. Multidisciplinary DEprescribing review for frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement. Research in Social and Administrative Pharmacy. 2023;19(8):1202–13.
2. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012 Mar;50(3):217–26.