Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study

Rationale Patients on dialysis are commonly prescribed multiple medications (polypharmacy), including some potentially inappropriate medications (PIMs). PIMs are associated with an increased risk of medication harm (e.g., falls, fractures, hospitalization). Deprescribing is a solution that proposes to stop, reduce, or switch medications to a safer alternative. Although deprescribing pairs well with routine medications reviews, it can be complex and time consuming. Whether clinical decision support improves the process and increases deprescribing for patients on dialysis is unknown. Objective To test the efficacy of the clinical decision support software MedSafer at increasing deprescribing for patients on dialysis. Study Design Prospective controlled quality improvement study with a contemporaneous control. Setting & Participants Patients prescribed ≥5 medications on two outpatient dialysis units in Montréal, Canada. Exposure Patient health data from the electronic medical record was input into the MedSafer web-based portal to generate reports listing candidate PIMs for deprescribing. At the time of a planned biannual medication review (usual care), treating nephrologists on the intervention unit additionally received deprescribing reports and patients received EMPOWER brochures containing safety information on PIMs they were prescribed. On the control unit, patients received usual care alone. Analytical Approach The proportion of patients with ≥1 PIMs deprescribed was compared between the intervention and control units following a planned medication review to determine the impact of using MedSafer. The absolute risk difference (aRD) with 95% confidence interval (CI) and number needed to treat (NNT) were calculated. Results 195 patients were included (127 control unit; 68 intervention unit); the mean age was 64.8 (SD=15.9) and 36.9% were female. The proportion of patients with ≥1 PIMs deprescribed on the control unit was 3.1% (4/127) vs. 39.7% (27/68) on the intervention unit [aRD=36.6% (95% CI=24.5-48.6; p<0.0001); NNT=3]. Limitations This was a single center non-randomized study at risk of type 1 error. Deprescribing durability was not assessed, and the study was not powered to reduce ADEs. Conclusions Deprescribing clinical decision support and patient EMPOWER brochures provided during medication reviews could be an effective and scalable intervention to address PIMs in the dialysis population. A confirmatory randomized controlled trial is needed. Registration NCT05585268.