Implementing a medication review and deprescribing intervention for older people living with frailty and polypharmacy in general practice: a feasibility study

Radcliffe and colleagues provide encouraging evidence that structured, pharmacist-led medication review can be delivered to older people living with frailty. Yet their most interesting finding may be the paradox: 72% of participants had at least one medicine stopped, 60% started at least one new medicine, and the mean medication count fell by only 0.27. Is this modest deprescribing or are we measuring the wrong outcome?

Deprescribing is often framed as therapeutic subtraction, yet good prescribing is bidirectional. STOPP/START deliberately couples potentially inappropriate medicines with prescribing omissions, recognising that optimisation may require both stopping and starting treatment.¹ A patient who stops two 'low-value' medicines but starts one clearly indicated treatment may finish with almost the same medication count and a substantially better regimen.

Yet this creates an uncomfortable methodological problem: if stopping is counted as successful deprescribing while starting is labelled optimisation, how can the intervention fail? I have previously argued that prescribing change is not synonymous with medicines optimisation.² MODIFY makes visible what might be called therapeutic turnover: simultaneous subtraction and addition within the same review. Crucially, reasons for initiating new medicines were not recorded. Were these additions correction of undertreatment, substitution, or simply medication churn?

The same pattern appears internationally. In a US pharmacist-led intervention, 81% of patients had at least one medicine discontinued and 78% had at least one medicine added; patients had a mean of 3.7 medicines stopped and 3.1 added, resulting in a net mean reduction of only 0.6 medicines per patient.³ The investigators appropriately described pharmacists as both deprescribing and prescribing.

Perhaps future trials should consider a bidirectional optimisation endpoint, judging both medicines stopped and medicines started against indication, likely harm, treatment burden, and patient priorities, rather than treating medication count as a surrogate for success. A patient moving from ten medicines to ten may have had an excellent review; one moving from ten to eight may not. Should deprescribing success be judged by what disappears or by whether the whole regimen is more appropriate afterwards?

References
1. O'Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023;14(4):625-632. doi:10.1007/s41999-023-00777-y.
2. Mokbel K. Structured medication reviews: prescribing change is not the same as medicines optimisation. Br J Gen Pract. 2026;76(769):346. doi:10.3399/bjgp26X746121.
3. Green AR, Quiles R, Daddato AE, et al. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc. 2024;72(7):1973-1984. doi:10.1111/jgs.18867.