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A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies.

Background: Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). Methods: Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber's preference IV in analyzing the treatment assignment-treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. Results: The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in providerlevel prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. Conclusions: Our results suggest that prescriber's preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD. [ABSTRACT FROM AUTHOR]

Introduction: Knowledge translation (KT) initiatives have the potential to improve prescribing quality and produce savings that exceed the cost of the KT program itself, including the cost of evaluation using pragmatic study methods. Our objective was to measure the impact and estimated savings resulting from the distribution of individualized physician portraits of statin prescribing along with therapeutic recommendations in British Columbia, Canada. Methods: A paired community design was used to study 2 725 family physicians in British Columbia. Communities were paired according to number of physicians and geographic location, with one community of each pair randomly assigned to an early (n = 1 349) or delayed (n = 1 376) intervention group. The intervention was a personalized prescribing portrait on statins that included therapeutic recommendations. The primary outcome was the impact on new prescribing (defined as statin naive) for primary prevention (defined as no diagnosis of cardiovascular disease) as recorded in the administrative claims databases of the BC Ministry of Health. Results: Compared to the delayed control group, the relative probability of a new statin prescription for primary prevention decreased by 6% in the 12 months after the Education for Quality Improvement in Patient Care (EQIP) portrait compared to the preceding 12 months (relative risk [RR] 0.94; 95% confidence interval [CI] 0.91-0.98). There was also a non-statistically significant decrease in new prescribing for secondary prevention in patients diagnosed with cardiovascular disease (RR 0.96; 95% CI 0.91-1.01). We estimated that 572 fewer patients started statins for primary prevention in the first year after the portrait was mailed compared to patients in the delayed practices. We estimated the statin cost for those patients as $465,000 in the first two years, while the KT program to provide statin portraits cost less than $100,000. Discussion: The individualized prescribing portrait had a significant beneficial effect on new statin prescribing for primary prevention but not secondary prevention. Provincial drug plan costs appear to have been reduced to a level that exceeded the cost of the program. (Contains 5 tables.)

Objectives The South Peace Polypharmacy Reduction Project is a quality improvement project in three communities in rural Canada that aimed to reduce polypharmacy and inappropriate prescribing practices in older adults. This study aims to evaluate the impact of a multifaceted intervention consisting of online team-based medication reviews and educational workshops on the number of chronic medications. Methods A controlled before-after design was used to compare if a decrease in the number of chronic medications was associated with the intervention comprising of online team-based medication reviews and educational workshops, compared with two matched control groups that received either a standard medication review or no medication review. Logistic regression models fit with generalized estimated equations were used to identify the impact of the interventions on decreasing the number of chronic medications. Key findings Following a medication review, the percentage of individuals that had deprescribed at least one medication was highest in the intervention group (52%), followed by the medication review controls at 45%, and 36% in non-medication review controls. Individuals in the intervention group were 20% more likely to have at least one medication deprescribed than individuals in the medication review control group (adjusted odds ratio: 1.20; 95% CI: 1.03 to 1.39), whereas they were 42% more likely to deprescribe at least one medication compared with non-medication review controls (adjusted odds ratio: 1.42; 95% CI: 1.25 to 1.61). Conclusions Online team-based medication reviews had a significant impact on decreasing the number of chronic medications in older adults. Furthermore, providing healthcare providers with education can complement the role of other healthcare interventions. [ABSTRACT FROM AUTHOR]

Introduction: Statements of commitment to change are advocated both to promote and to assess continuing education interventions. However, most studies of commitment to change have used self-reported outcomes, and self-reports may significantly overestimate actual performance. As part of an educational randomized controlled trial, this study documented changes that family physicians committed to make in their prescribing and then used third-party data to examine actual changes. Method: Following participation in a continuing medical education program using interactive small groups, physicians were asked to identify changes that they planned to make in their practices. For prescribing changes related to four conditions, data from a provincial pharmacy registry were analyzed for 6-month periods before and after the educational intervention. Results: A total of 207 physicians participated in the project, which involved monthly meetings of 30 peer learning groups. Ninety-nine physicians received experimental case-based educational modules plus or minus personal prescribing feedback, and 91 of these indicated that they planned to make at least one change in practice. Of the 209 intended changes, 71% were directly related to the prescribing messages in the materials. Discussion: In three of four indicator conditions, physicians who expressed a commitment to change were significantly more likely to change their actual prescribing for the target medications in the following 6 months. The percentage of physicians who did change their prescribing varied significantly by condition. Further study of the process of translating commitment to change into real practice change is needed. (Contains 5 figures and 2 tables.)