Original Study| Volume 22, ISSUE 1, P82-89.e3, January 2021

Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial



      Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.


      Pragmatic multicenter stepped-wedge cluster randomized controlled trial.

      Setting and Participants

      Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.


      The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.


      Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians.

      Conclusions and Implications

      Multidisciplinary medication review–directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.


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        • Lee S.W.
        • Mak V.S.
        Changing demographics in Asia: A case for enhanced pharmacy services to be provided to nursing homes.
        J Pharm Pract Res. 2016; 46: 152-155
        • Morin L.
        • Laroche M.L.
        • Texier G.
        • Johnell K.
        Prevalence of potentially inappropriate medication use in older adults living in nursing homes: A systematic review.
        J Am Med Dir Assoc. 2016; 17: 862.e1-862.e9
        • Ziere G.
        • Dieleman J.P.
        • Hofman A.
        • et al.
        Polypharmacy and falls in the middle age and elderly population.
        Br J Clin Pharmacol. 2006; 61: 218-223
        • Bennett A.
        • Gnjidic D.
        • Gillett M.
        • et al.
        Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug–drug interactions in robust versus frail hospitalised falls patients: A prospective cohort study.
        Drugs Aging. 2014; 31: 225-232
        • Scott I.A.
        • Hilmer S.N.
        • Reeve E.
        • et al.
        Reducing inappropriate polypharmacy: The process of deprescribing.
        JAMA Intern Med. 2015; 175: 827-834
        • Marvin V.
        • Ward E.
        • Poots A.J.
        • et al.
        Deprescribing medicines in the acute setting to reduce the risk of falls.
        Eur J Hosp Pharm. 2017; 24: 10-15
        • Thompson W.
        • Farrell B.
        Deprescribing: What is it and what does the evidence tell us?.
        Can J Hosp Pharm. 2013; 66: 201-202
        • Masnoon N.
        • Shakib S.
        • Kalisch-Ellett L.
        • Caughey G.E.
        Tools for assessment of the appropriateness of prescribing and association with patient-related outcomes: A systematic review.
        Drugs Aging. 2018; 35: 43-60
        • Fick D.M.
        • Semla T.P.
        • et al.
        • American Geriatrics Society 2015 Beers Criteria Update Expert Panel
        American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2015; 63: 2227-2246
        • O'mahony D.
        • O'sullivan D.
        • Byrne S.
        • et al.
        STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2.
        Age Ageing. 2015; 44: 213-218
        • Hamilton H.
        • Gallagher P.
        • Ryan C.
        • et al.
        Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients.
        Arch Intern Med. 2011; 171: 1013-1019
        • Fick D.M.
        • Semla T.P.
        • et al.
        • 2019 American Geriatrics Society Beers Criteria® Update Expert Panel
        American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2019; 67: 674-694
        • Lavan A.H.
        • Gallagher P.
        • Parsons C.
        • O'Mahony D.
        STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): Consensus validation.
        Age Ageing. 2017; 46: 600-607
        • Pazan F.
        • Weiss C.
        • Wehling M.
        The FORTA (Fit fOR The Aged) list 2015: Update of a validated clinical tool for improved pharmacotherapy in the elderly.
        Drugs Aging. 2016; 33: 447-449
        • Pitkälä K.H.
        • Juola A.L.
        • Kautiainen H.
        • et al.
        Education to reduce potentially harmful medication use among residents of assisted living facilities: A randomized controlled trial.
        J Am Med Dir Assoc. 2014; 15: 892-898
        • García-Gollarte F.
        • Baleriola-Júlvez J.
        • Ferrero-López I.
        • et al.
        An educational intervention on drug use in nursing homes improves health outcomes resource utilization and reduces inappropriate drug prescription.
        J Am Med Dir Assoc. 2014; 15: 885-891
        • Juola A.L.
        • Bjorkman M.P.
        • Pylkkanen S.
        • et al.
        Nurse education to reduce harmful medication use in assisted living facilities: Effects of a randomized controlled trial on falls and cognition.
        Drugs Aging. 2015; 32: 947-955
        • Lee S.W.
        • Mak V.S.
        • Tang Y.W.
        Pharmacist services in nursing homes: A systematic review and meta-analysis.
        Br J Clin Pharmacol. 2019; 85: 2668-2688
        • Gemelli M.G.
        • Yockel K.
        • Hohmeier K.C.
        Evaluating the impact of pharmacists on reducing use of sedative/hypnotics for treatment of insomnia in long-term care facility residents.
        Consult Pharm. 2016; 31: 650-657
        • Lapane K.L.
        • Hughes C.M.
        • Daiello L.A.
        • et al.
        Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.
        J Am Geriatr Soc. 2011; 59: 1238-1245
        • Patterson S.M.
        • Hughes C.M.
        • Crealey G.
        • et al.
        An evaluation of an adapted US model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland study).
        J Am Geriatr Soc. 2010; 58: 44-53
        • Kua C.H.
        • Yeo C.Y.Y.
        • Char C.W.T.
        • et al.
        Nursing home team-care deprescribing study: A stepped-wedge randomised controlled trial protocol.
        BMJ Open. 2017; 7: e015293
        • Hemming K.
        • Taljaard M.
        • McKenzie J.E.
        • et al.
        Reporting of stepped wedge cluster randomised trials: Extension of the CONSORT 2010 statement with explanation and elaboration.
        BMJ. 2018; 363: k1614
        • World Medical Association
        World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects.
        Bull World Health Organ. 2001; 79: 373
        • Farrell B.
        • Mangin D.
        Deprescribing is an essential part of good prescribing.
        Am Fam Physician. 2019; 99: 7-9
        • Oliveira M.G.
        • Amorim W.W.
        • de Jesus S.R.
        • et al.
        A comparison of the Beers and STOPP criteria for identifying the use of potentially inappropriate medications among elderly patients in primary care.
        J Eval Clin Pract. 2015; 21: 320-325
        • Elderly and Continuing Care Division
        A Guidebook on Nursing Homes.
        Ministry of Health, Singapore2002
        • Stapleton C.
        • Hough P.
        • Oldmeadow L.
        • et al.
        Four-item fall risk screening tool for subacute and residential aged care: The first step in fall prevention.
        Australas J Ageing. 2009; 28: 139-143
        • Nunan S.
        • Brown Wilson C.
        • Henwood T.
        • Parker D.
        Fall risk assessment tools for use among older adults in long-term care settings: A systematic review of the literature.
        Australas J Ageing. 2018; 37: 23-33
        • Woertman W.
        • de Hoop E.
        • Moerbeek M.
        • et al.
        Stepped wedge designs could reduce the required sample size in cluster randomized trials.
        J Clin Epidemiol. 2013; 66: 752-758
        • Strand L.M.
        • Morley P.C.
        • Cipolle R.J.
        • et al.
        Drug-related problems: Their structure and function.
        DICP. 1990; 24: 1093-1097
        • Rubenstein L.Z.
        Preventing falls in the nursing home.
        JAMA. 1997; 278: 595-596
        • Hjaltadóttir I.
        • Hallberg I.R.
        • Ekwall A.K.
        • Nyberg P.
        Predicting mortality of residents at admission to nursing home: A longitudinal cohort study.
        BMC Health Serv Res. 2011; 11: 86
        • Gómez C.
        • Vega-Quiroga S.
        • Bermejo-Pareja F.
        • et al.
        Polypharmacy in the elderly: A marker of increased risk of mortality in a population-based prospective study (NEDICES).
        Gerontology. 2015; 61: 301-309
        • Leelakanok N.
        • Holcombe A.L.
        • Lund B.C.
        • et al.
        Association between polypharmacy and death: A systematic review and meta-analysis.
        J Am Pharm Assoc. 2017; 57: 729-738
        • Gnjidic D.
        • Le Couteur D.G.
        • Kouladjian L.
        • Hilmer S.N.
        Deprescribing trials: Methods to reduce polypharmacy and the impact on prescribing and clinical outcomes.
        Clin Geriatr Med. 2012; 28: 237-253
        • Page A.T.
        • Clifford R.M.
        • Potter K.
        • et al.
        The feasibility and effect of deprescribing in older adults on mortality and health: A systematic review and meta-analysis.
        Br J Clin Pharmacol. 2016; 82: 583-623
        • Kua C.H.
        • Mak V.S.
        • Lee S.W.
        Health outcomes of deprescribing interventions among older residents in nursing homes: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2019; 20: 362-372
        • Xie Y.
        • Bowe B.
        • Li T.
        • et al.
        Risk of death among users of proton pump inhibitors: A longitudinal observational cohort study of United States veterans.
        BMJ Open. 2017; 7: e015735
        • Gray S.L.
        • Anderson M.L.
        • Dublin S.
        • et al.
        Cumulative use of strong anticholinergics and incident dementia: A prospective cohort study.
        JAMA Intern Med. 2015; 175: 401-407
        • Nursing Home Standards Workgroup
        Enhanced Nursing Home Standards.
        Ministry of Health, Singapore2014
        • Bird M.L.
        • Pittaway J.K.
        • Cuisick I.
        • et al.
        Age-related changes in physical fall risk factors: results from a 3 year follow-up of community dwelling older adults in Tasmania, Australia.
        Int J Environ Res Public Health. 2013; 10: 5989-5997