RESULTS
All studies identified were assessed to have at least a moderate risk of bias and most had a critical risk of bias. Five RCTs and 2 pilot RCTs were identified. Four of these studies reported a statistically significant reduction of medications or PIMS in the control group. However, many studies were of small size, completed at a single centre, and were pilot studies or prospective in design.
The identified studies span a range of specialist outpatient clinics. The majority of interventions have been evaluated within geriatric outpatient clinics.25-32 Two studies measured deprescribing interventions in oncology/haematology clinics,33,34 and 2 studies examined outpatient haemodialysis patients.35,36 Other locations included a memory clinic,37 heart failure clinic,38 and geriatric preoperative clinic39 and pilot studies looking at designated polypharmacy/multimorbidity review clinics.40-43
The included studies ranged from no follow-up post-intervention, to 2-years of follow-up. They have used a range of screening instruments to identify PIMs and to review, optimize, and assess deprescription of medications. The well validated Beers criteria44 and STOPP/START criteria45 were the most often used explicit tools applied to identify PIMS. The Medicines Appropriateness Index (MAI) was also used in some instances as an implicit tool to assess the appropriateness of all medication by looking at indication, efficacy, dose, directions, interactions, duration, duplication, and cost.46 Less well published tools adopted include the Individualised Medication Assessment and Planning (iMAP) tool that has been more recently developed specifically for assessing and resolving medication-related problems in outpatients47 and the FORTA (Fit for the Aged) list and scoring system, which evaluates patients medication for undertreatment, overtreatment, and mistreatment.48 Several other studies have used their own algorithms and grouped medication related issues into a set of ‘drug-related problems’.33,38 Within specialized settings, such as oncology, palliative care, and haemodialysis, the need for additional screening tools has been identified as essential to address condition-specific considerations, such as specific drug-interactions or intolerances and treatment goals.36,49