How to do it?
Guidance from the United Kingdom Medical Research Council on developing
and evaluating complex interventions provides a suitable framework for
deprescribing intervention development, from selecting intervention
components and translating these into an intervention package, through
to feasibility testing and evaluation.(4) Many of the behavioural
strategies, sometimes described as behaviour change techniques (active
components of the intervention) used in deprescribing are relevant for
broader medicines optimisation approaches, and so components of
interventions may be interchangeable. However when it comes to
operationalisation of either process in practice, there may be
differences.(5)
Considering how the intended target and scope reflect the reality of
clinical practice is important for intervention development. Often
patients may have more than one medication issue that requires
intervention, and an accumulation of single interventions targeting
various medication issues may increase workload for providers. This may
also add to the substantial treatment burden among people with
multimorbidity (i.e. the work required to manage their conditions),
associated with delivery of care centred around many single conditions
and disease guidelines. A suite of components as part of a complex
intervention targeting multiple medicines may provide a more cohesive,
and sustainable, approach than multiple single-medicine focused
interventions. The acceptability of these approaches should also be
considered; clinicians and patients may find efforts to optimise all
medicines at the outset challenging, whereas starting with a single
medicine may provide early success encouraging an incremental approach
to optimise multiple medicines.
Targeting multiple medicines presents additional complexity to an
intervention, such as in assessing what should be deprescribed (or
optimised), and how to do it. An intervention may have to involve
multiple criteria to identify medications to deprescribe or optimise,
and a set of medication-specific deprescribing guidance. Alternatively,
a more general approach relying on implicit judgement of the healthcare
professional could be used, which will increase heterogeneity in
intervention delivery. In contrast, a single medication target may allow
a greater degree of specification of the approach to deprescribing or
medicines optimisation, likely yielding greater intervention fidelity.
Where changes to multiple medications are required, the need to decide
the priority, timing, and order of these changes will also increase the
potential for variation in intervention delivery.(6) This may have
implications for deciding when to measure outcomes in a study. The time
to implement multiple medication changes may be highly variable between
patients. For example, medications may require varying lengths of time
to taper while deprescribing, and some medications may be deprescribed
sequentially rather than all at once. Therefore, the study length of
follow-up will need to be sufficient to allow all changes to be
implemented, and for any effect on outcomes to occur.