Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review

<b>Introduction</b>: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life. <b>Areas covered</b>: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events. <b>Expert opinion</b>: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.

<b>引言</b>：多重用药（Polypharmacy）在临床医院中十分普遍，老年患者的处方精简（deprescribing）策略亦得到广泛推广。然而，针对接受临终关怀的患者群体，此类策略的可行性与可持续性相关研究证据仍较为匮乏。本综述旨在评估医院发起的处方精简策略，针对临终阶段老年患者的临床有效性，以及该策略在患者出院后的可持续性。

<b>综述覆盖范围</b>：研究团队检索了偏倚风险较低、且包含出院后有效性评估指标的对照试验。针对干预措施的具体内容、实施周期，以及医疗服务提供者的参与度，研究分析了其对以下指标的影响：用药数量减少情况、不恰当用药患者的占比、急诊复诊率、住院率，以及不良事件发生率。

<b>专家意见</b>：现有有限证据表明，医院发起的处方精简干预或可在短期内改善终末期老年患者的不恰当用药现状，但针对3个月以上的随访周期，尚无足够证据证明其可有效预防不良事件或减少医疗服务资源的使用。研究间的异质性导致无法开展元分析（Meta-Analysis），而随访周期过短也使得无法对干预的可持续性进行量化评估。未来仍需开展大样本量、长随访周期的终末期老年患者临床试验，以验证临终阶段处方精简策略的有效性与可持续性；同时，可靠识别近临终状态的客观工具，将有助于精准筛选此类干预措施的目标人群。