Introduction
Worldwide, our populations are living longer, but with a greater burden of health conditions. The presence of multiple conditions (i.e. multimorbidity) drives prescribing of medications, and many people, in particular older adults, are on multiple medications (or polypharmacy).(1) Medications are often continued when they are no longer needed or pose a greater risk of harm than benefit. Such potentially inappropriate prescribing can impact quality of life, cause adverse drug reactions, consume healthcare resources, and increase mortality.(1)
Deprescribing, the process of stopping or reducing such medications, is one important way to address this.(2) Deprescribing interventions focus on actions to reduce the number of medications, congruent with the historical view that polypharmacy is inappropriate and increases risk of harm. However, there is increasing recognition that the number of medicines itself is not harmful, as having multiple long-term conditions may need multiple medicines. Therefore, improving the appropriateness of polypharmacy through medicines optimisation may involve starting or increasing medicines as well as stopping in many circumstances.(3) Deprescribing can be considered as one important component of medicines optimisation. Given the many barriers to deprescribing and limited implementation in routine practice, it is understandable that significant attention is given to assessment of deprescribing interventions as a high priority.(2)
There is substantial heterogeneity among trials which evaluate deprescribing, as many interventions also combine deprescribing with other actions to promote appropriate polypharmacy.(3) There can be variation in the study designs used (e.g. randomised trials, controlled before and after studies), as well as important differences in the intervention target (focused on one medication or many) and the scope of the intervention (solely deprescribing, or also including other aspects of medicines optimisation in addition to deprescribing).
In developing and evaluating deprescribing interventions, the decisions regarding the intervention target and scope are critical. Here, we reflect on how these decisions (one versus many medications, and deprescribing versus medicines optimisation) can affect other study design considerations, specifically developing interventions and measuring outcomes.