Table 2 Documents included in the realist review (n = 28)

Bryant, L. J., et al., (2010) [37] New Zealand

Randomised Controlled Trial (RCT)

Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient’s general practitioner (GP) to discuss recommendations about possible medicine changes

198 patients, aged 65 and over, taking 5 medicines or more

To determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients

Campins, L., et al. (2017) [38] Spain

RCT

The intervention consisted of 3 consecutive phases

1. A trained, experienced clinical pharmacist evaluated all drugs prescribed to each patient using the GP–GP algorithm and appropriateness based on the STOPP/START criteria

2. The pharmacist discussed recommendations for each drug with the patient’s GP to come up with a final set of recommendations

3. Recommendations were discussed with the patient, and a final decision was agreed by GP and their patients in a face-to-face visit

503 patients, aged 70 and over, taking 8 medicines or more

To assess the effectiveness and safety of a medication evaluation programme for community-dwelling polymedicated elderly people

Cardwell, K., et al. (2020) [39] Ireland

Non-randomised pilot study

A pharmacist joined the practice team for 6 months (10 h/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education

786 patients, aged 65 years and over, taking 10 repeat medicines or more

To develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland

Clark, C. M., et al. (2003) [40] USA

Evaluation of a pilot program

Community pharmacy-based clinical pharmacist provided face-to-face medication reviews for patients over 65 years old as part of their Annual Wellness Visit with a focus on deprescribing PIMs. No clinical pharmacy service existed at the practice when this program was implemented

21 patients aged 65 years and over, living in the community

To develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit to make deprescribing recommendations targeted at PIMs in seniors

Mecca, M. C., et al. (2019) [41] USA

A prospective cohort study with an internal comparison group

The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created as an interprofessional education intervention to provide a platform for teaching internal medicine and nurse practitioner residents about outpatient medication management and deprescribing for older adults

36 patients, aged 65 years and over, taking 10 medicines or more

To assess patients’ knowledge of polypharmacy and perceptions of an interprofessional education intervention

Lenaghan, E., et al. (2007) [42] UK

RCT

The intervention comprised two home visits by a community pharmacist who educated the patient/carer about their medicines, noted any pharmaceutical care issues, assessed need for an adherence aid, and subsequently met with the lead GP to agree on actions

41 patients, aged 80 years and over, living at home, taking four or more medicines, with at least one additional medicines-related risk factor

To assess whether home-based medication review by a pharmacist for at-risk older patients in a primary care setting can reduce hospital admissions

Leendertse, A. J., et al. (2013) [43] The Netherlands

An open controlled multicentre study

The intervention consisted of a patient interview, a review of the pharmacotherapy and the execution and follow-up evaluation of a pharmaceutical care plan. The patient’s own pharmacist and GP carried out the intervention

674 patients with a high risk of medication-related hospitalizations based on age 65 years and over), use of five or more medicines, non-adherence and type of medication used

To investigate the effect of a multicomponent pharmaceutical care intervention on these outcomes

Lenander, C., et al. (2014) [44] Sweden

RCT

Patients answered a questionnaire regarding medications. The pharmacist reviewed all medications (prescription, non-prescription, and herbal) regarding recommendations and renal impairment, giving advice to patients and GPs. Each patient met the pharmacist before seeing their GP

209 patients aged 65 years and over with five or more different medications

To determine whether a pharmacist-led medications review in primary care reduces the number of drugs and the number of drug-related problems

Khera, S., et al. (2019) [45] Canada

Quasi-experimental pre-test-post-test design

A structured pharmacist-led medication review using evidence-based explicit criteria (ie, Beers and STOPP/START criteria) and implicit criteria (i.e., pharmacist expertise) for potentially inappropriate prescribing

54 patients aged 65 years and over with frailty who have polypharmacy and/or 2 or more chronic conditions (ie, high-risk group for drug-related issues)

To assesses the impact of a team-based, pharmacist-led structured medication review process in primary care on the appropriateness of medications taken by older adults living with frailty

Hazen, A. C. M., et al. (2019) [46] The Netherlands

An observational cross-sectional study

Clinical medication reviews led by non-dispensing pharmacists. The medication review started with a semi-structured interview with the patient identifying the patient’s experiences, needs and concerns about medication. These were integrated with the medical records to determine potential drug therapy problems. The pharmacist developed a pharmaceutical care plan in collaboration with the patient and the GP, including recommendations to stop, start or switch medication, to adjust dosages or to improve adherence to medication. The recommendations were implemented and monitored, mainly by the pharmacist

270 patients aged 65 years and over using 5 or more chronic medications

To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved

Foubert, K., et al. (2019) [47] Belgium

Prospective observational study

Participating pharmacists received protocol training. Pharmacists conducted a face-to-face intermediate medication review based on medication history and patient information, according to Pharmaceutical Care Network Europe typology of medication reviews using the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP3S)‐tool and other sources of information if necessary

75 patients aged 70 and over, using five or more medications

To describe the characteristics of the detected drug related problems (DRPs) and the subsequent pharmacists' recommendations with their acceptance and implementation rate resulting from a pharmacist‐led medication review using the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP3S)‐tool (an explicit screening tool to detect DRPs) and to assess the potential impact of the intervention

Fixen, D. R., et al. (2022) [48] USA

Retrospective review

Patients were mailed an education packet of information that included working with the clinical pharmacy team, behavioural health team, or both in order to deprescribe their sedative-hypnotic medication

93 ‘Older adults’ with a prescription filled in the prior 12 months for a sedative-hypnotic medication, benzodiazepine or nonbenzodiazepine sedative-hypnotic (ie, zolpidem, zaleplon, eszopiclone) were included

To evaluate the outcome of a multidisciplinary intervention tailored to older adult patients and their primary care providers (PCP)

Verdoorn, S., et al. (2019) [49] The Netherlands

RCT

A clinical medication review (CMR) focused on personal goals using Goal Attainment Scaling (GAS), starting with a face-to-face patient interview by the pharmacist

315 patients aged 70 years or more using 7 or more medications

The aim of this study was to investigate whether GAS is a useful tool for determining goals and monitoring their attainment during CMR

Williams, M. E., et al. (2004) [50] USA

RCT

A comprehensive review by a consultant pharmacist and recommended modification of a patient’s medication regimen. Changes were endorsed by each patient’s primary physician and discussed with each patient

133 patients aged 65 and over taking five or more medications

To determine whether a medication review by a specialized team would promote regimen changes in elders taking multiple medications and to measure the effect of regimen changes on monthly cost and functioning

Fiss T., et al. (2013) [51] Germany

We conducted a prospective non-randomized implementation cohort study

The intervention was implemented by a three -party healthcare team (practice assistant, pharmacist, GP)) and adherence supporting strategies (using a medication reminder chart, medication compliance aid). It comprised pharmaceutical care (and follow-up visit) by the local pharmacy in addition to medical interventions by the GP

408 patients, aged 65 and over with ‘any intake of drugs'

To answer the following questions: -Is home medication review in a tripartite setting, with subsequent pharmaceutical and medical interventions, effective in reducing specific DRPs in a German rural area, and how many drugs are the patients taking?

-Is it possible to improve adherence supporting strategies with a medication plan / medication reminder chart and a medication box?

Stuhec, M. (2021) [52] Slovenia

A pilot trial

The model for Slovenian primary care settings had teams of one clinical pharmacist and all GPs from a primary care setting (e.g., 10 GPs and one pharmacist). Teams consisted of all GPs at a primary care setting and a clinical pharmacist working in the GPs’ offices. GPs could refer patients to the clinical pharmacist for a medication review. The clinical pharmacist prepared a medication review and final recommendations which were sent back to the GPs. The GPs could accept or reject the recommendations at the patient’s next regular visit

48 patients, aged 65 and over

To evaluate a programme in Slovenia to reduce medication-related problems and polypharmacy in the older adult with polypharmacy

Van der Meer, H. G., et al. (2018) [53] The Netherlands

RCT

A medication review by the community pharmacist in collaboration with the patient’s GP and patient

305 patients aged 65 years and over who used 5 or more medicines for 3 months or more, including at least one psycholeptic/psychoanaleptic medication and who had a Drug Burden Index (DBI) of 1 or more

To evaluate if a pharmacist-led medication review is effective at reducing the anticholinergic/ sedative load, as measured by the DBI

Van der Meer, H. G., et al. (2019) [54] The Netherlands

Prospective study

Information technology (IT) based tool developed by researchers aimed at identifying patients at risk of newly prescribed anticholinergic drug use, these patients would then be reviewed by a community pharmacist whose recommendations were brought to the GP. This was then presented to the patient by either pharmacist or GP

157 patients, aged 65 years and over, with existing high anticholinergic/sedative loads (drug burden index 2 or more) and a newly initiated anticholinergic/sedative medication

To explore the feasibility, acceptability and potential effectiveness of an innovative IT-based intervention to prevent an increase in anticholinergic/sedative load in older people

Oboh L., et al. (2018) [55] UK

Evaluation based on systematic anonymised data recorded regarding full operation of the integrated care clinical pharmacist service in its first 15 months

Community Matrons (CMs) identified patients who were experiencing medicines related problems. These were referred to the integrated care clinical pharmacist who undertook a full medication review at the patient’s home and recorded activities, which were independently analysed anonymously

143 patients. ‘Frail, older patients with complex medicines-related needs living in their own homes’. CMs identified and referred those patients from their active caseload who were experiencing actual medicines-related problems or those who had other challenges affecting medicine-taking. There were no exclusion criteria

To describe a new specialist pharmacy service (called the integrated care clinical pharmacist) in terms of how it works, what it achieves and its policy implications

Parkinson, L., et al. (2021) [56] Australia

Pilot study

A pharmacist home review and discussion of patients’ medications, communication between pharmacist and GP, and a GP–patient discussion, all facilitated through AusTAPER. AusTAPER integrates patient priorities, decision- support tools to electronically flag potentially inappropriate medicines and a clinical pathway for structured assessment and follow-up by both community pharmacist and GP in a web-based system

Nine patients and two GPs responded. (Patients aged 70 years or older, taking at least five regular medicines)

The objective of this study was to explore the Australian general practitioner (GP) and patient experience of AusTAPER, a pharmacist facilitated web-based deprescribing tool, within a pilot implementation of the tool

Romskaug, R., et al. (2019) [57] Norway

Cluster randomized, single-blind, clinical trial

The intervention consisted of 3 main parts: (1) clinical geriatric assessment of the patients combined with a thorough review of their medications; (2) a meeting between the geriatrician and the family physician (FP); and (3) clinical follow-up

174 patients, home-dwelling patients 70 years or older, using at least 7 medications regularly, and having their medications administered by the home nursing service

To investigate the effect of clinical geriatric assessments and collaborative medication reviews by geriatrician and FP on health-related quality of life and other patient-relevant outcomes in home-dwelling older patients receiving polypharmacy

Dalin, D. A., et al. (2019) [58] Denmark

Evaluation

Medication review in general practice by an interdisciplinary medication team of pharmacists and physicians, based on information concerning medication, diagnosis, relevant laboratory data and medical history supplied by the general practitioner. The medication review was discussed with the patients’ general practitioners and feedback was received from them regarding acceptance rates of the recommended changes

94 patients, aged 65 years and over, using 6 or more medications

The study objective is to describe and evaluate a method for conducting medication review in general practice by an interdisciplinary medication team of pharmacists and physicians

Denneboom, W., et al. (2007) (a) [59] The Netherlands

RCT

Pharmacists were randomised and the pharmacists in both intervention groups performed treatment reviews with the support of the computerised screening tool. They had to decide which of the recommendations highlighted by the tool should be given to the GP, and whether additional recommendations concerning the pharmacotherapy of these patients should be highlighted. The two intervention groups differed in their organisational models (written-feedback by pharmacists to GP vs case-conference between the pharmacist and GP)

738 patients, aged 75 years and over taking five or more medicines

To determine which procedure for treatment reviews (case conferences versus written feedback) results in more medication changes, measured at different moments in time. To determine the costs and savings related to such an intervention

Denneboom, W., et al. (2007) (b) [60] The Netherlands

Written questionnaires, structured telephone interviews

As above (Process evaluation for the study above)

64 GPs and 28 pharmacists responded to a questionnaire. 18 Pharmacists and 16 GPs participated in telephone interviews

The aim of the study was to describe the feasibility of two methods for treatment review (results were given to the GP either in case conferences or in written feedback), and to determine if and how the process of treatment review can be improved

Bayliss E. A., et al. (2022) [61] USA

Cluster RCT

An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings

3012 patients aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications

To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment

Sheehan et al. O.C., (2022) [62] USA

Qualitative interviews and surveys with stakeholders

As above (Process evaluation for the study above)

15 patients, 7 caregivers, and 28 clinicians, participating in the above study

To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment

Trenaman S. C., et al. (2022) [63] Canada

The evaluation included measures of medication appropriateness, patient satisfaction, and healthcare professional satisfaction

Pharmacist-led deprescribing in collaborative primary care settings using the seven components of knowledge translation. Patient and stakeholder engagement shaped the deprescribing intervention. The seven essential components of knowledge translation include identification of a problem, adaptation of knowledge to local context, assessment of barriers to knowledge use, selection, tailoring, and implementation of an intervention, monitoring knowledge use, evaluation of outcomes, and sustaining knowledge use

13 patients, across the three sites. Patients who have stable management of all chronic conditions, taking medications from a targeted drug list and have not had a change in the targeted medication for the past three months

To describe implementation of pharmacist-led deprescribing in collaborative primary care settings using the seven components of knowledge translation

Jamieson H., et al. (2023) [64] New Zealand

RCT

Pharmacists provided deprescribing recommendations by letter to GPs. Each participant experienced a home-based pharmacist-conducted medication review. All pharmacists received training specific to the intervention and followed the deprescribing guidelines defined in the study protocol. The pharmacist did not have access to the participants’ clinical notes or medication records and all clinical decision-making, including prescribing, remained with the GP

363 patients, aged 65 and over, identified as frail based on a needs assessment, taking at least 1 medication with anticholinergic or sedative effects regularly at the minimum registered daily adult dose (which would result in DBI of 0.5 or above)

To test, by conducting an RCT, whether patient-specific deprescribing recommendations developed by pharmacists following a medication review and provided to the patient’s GP reduced the use of anticholinergic and sedative medications. In addition, we hypothesized that any resulting reduction in DBI score would be more pronounced for older adults with a greater level of frailty