Background: the Rationale for a Deprescribing Competency Framework

As the population ages, healthcare professionals will encounter older adults with multiple chronic conditions taking many medications, for whom the balance of potential benefit and harm from medications may shift over time. Decisions related to continuing, reducing, or stopping medications, especially in older adults, can be difficult. There is a growing need to standardize the teaching and assessment of deprescribing knowledge and skills to address these challenges.

In 2016, one-quarter of Canadian seniors were prescribed ten or more medications, with half treated with at least one medication on the American Geriatrics Society Beers Criteria® list of “potentially inappropriate medications” (PIMs) [1, 2]. The prevalence of PIMs and polypharmacy (use of unnecessary medications, or medications where harm outweighs benefit) [3, 4] has risen steadily internationally over the past two decades [5,6,7,8]. As the number of PIMs increases, so too does the risk of adverse drug events (ADEs) [9], drug-drug interactions [10], hospital admissions [9, 11, 12], and mortality [13, 14]. Medications may become potentially inappropriate when they are continued longer than intended (e.g., proton pump inhibitors, antidepressants) [15], or when many are used to treat multiple chronic conditions resulting in additive harmful effects [16,17,18], or when they are continued in the context of frailty [19,20,21], dementia [22], or end-of-life care [23, 24] when the beneficial effect is no longer evidence-based [25, 26], apparent, or aligned with the patient’s goals of care. Growing risk of medication harm is related to progressive functional decline and pharmacodynamic changes that, for example, increase sensitivity to cardiovascular medications, anticoagulants, opioids, antipsychotics, and benzodiazepines [27,28,29,30].

Deprescribing is the patient-centered, planned, and supervised process of dose reduction or stopping of a medication that may be causing harm or may no longer be providing benefit [31]. It is a fundamental component of appropriate prescribing which can improve quality of life and medication adherence while reducing ADEs, system cost, and patient expense [32,33,34]. Deprescribing, with appropriate monitoring, is safe [35], with non-randomized studies suggesting deprescribing can reduce mortality [36].

There is international agreement that problematic polypharmacy must be addressed and that deprescribing is a vital solution. The World Health Organization (WHO) Medication Without Harm – Global Patient Safety Challenge on Medication Safety, launched in 2017, aims to reduce severe, avoidable medication-related harm by 50% in 5 years. The WHO describes the importance of considering deprescribing in medication reviews and attending to deprescribing as robustly as prescribing [37]. Likewise, the Australian and Scottish governments and the Lown Institute in America have identified the importance of reducing polypharmacy and educating and training health professionals to reduce medication overload [38,39,40]. Since 2015, the Canadian Deprescribing Network has been working both nationally and provincially with the public, healthcare professionals, and policymakers to raise awareness about medication safety, deprescribing, and promoting increased access to safer pharmacologic and non-pharmacologic therapies [41, 42]. Other national and international deprescribing networks have also been launched to address the growing concerns regarding aging, polypharmacy, and medication-related harm [43,44,45].

It is well documented that a number of barriers to deprescribing exist [46,47,48,49,50,51]. Physicians, pharmacists, nurses, and other healthcare professionals have identified knowledge and skill deficits regarding polypharmacy management, PIM use, balancing medication benefits and harms, and difficulties recognizing ADEs and prescribing cascades. These and other deprescribing concepts are beginning to be taught in some undergraduate programs, but implementation is inconsistent and non-standardized; learners continue to express low confidence and self-efficacy for deprescribing [47, 52,53,54,55,56,57,58,59].

To prepare interdisciplinary teams to deprescribe, we must address these deficits by consistently teaching principles, knowledge, and skills required for effective evidence-based deprescribing. While physicians, pharmacists, and nurses prescribe, deprescribe, dispense, administer, and monitor medications, other healthcare professionals can also identify patients who may benefit from medication review, deprescribing, and non-pharmacological approaches to care [60,61,62,63,64,65,66,67]. Ideally, a structured, robust curriculum within each respective healthcare program should present prescribing principles and assessments to ensure the implementation of appropriate deprescribing practices.

Currently, deprescribing competencies are taught and assessed to varying degrees (or not at all) within healthcare curricula across Canada. A 2018 international symposium on deprescribing education [68] acknowledged that deprescribing skills are not consistently taught or assessed in many countries. Subsequently, members of the Canadian Deprescribing Network’s Healthcare Providers Education Committee, an interprofessional group, sought input from Canadian healthcare professional educators, deprescribing leaders, and clinicians involved in the care of older people. Through an iterative process involving literature review, consultation and several rounds of discussion and revision and group consensus, we developed this position paper to provide guidance on teaching and assessing deprescribing as part of a continuum of appropriate prescribing within an interprofessional context.

This paper targets educators in medicine, pharmacy, and nursing involved in the design and delivery of entry-to-practice (pre-licensure) programs and organizations that accredit these. It also supports the education of other healthcare professionals (e.g., physiotherapists, occupational therapists, dietitians, dentists, speech-language pathologists, social workers) who can identify medication safety concerns or adverse drug effects, and who may recommend non-pharmacological approaches that reduce reliance on medications [61].

The objective of this paper is to provide a deprescribing competency curriculum framework for medicine, nursing, and pharmacy entry-to-practice degree programs. To enable educators to systematically integrate and assess deprescribing knowledge into their teaching and clinical practices, we propose a draft competency framework, options for learning outcomes at various levels, teaching and assessment strategies, and a toolkit of practical resources for curricular and experiential learning. We anticipate that this work will be applicable internationally although it is written from a Canadian perspective. Much of the polypharmacy and deprescribing research and clinical practice initiatives emerge from work in geriatric medicine. Therefore, this paper focuses on deprescribing in the context of care of older people, though we encourage curriculum developers to consider components of the framework in relation to other populations. Ultimately, our goal is to have health professional educators use this framework to identify and implement opportunities for their students to attain competencies in deprescribing.

Proposed Deprescribing Competency Framework

Deprescribing should be aligned with good prescribing. Several Canadian regulatory bodies, educators, and researchers have adopted the Royal Pharmaceutical Society’s (RPS) Competency Framework for All Prescribers, which lists ten competencies for prescribing: six address consultation and patient-centered care and four relate to prescribing governance [69]. The Royal College of Physicians and Surgeons of Canada (RCPSC) developed competencies for prescribing in their Prescribing Safely Canada initiative, with ten competencies, seven of which relate to patient and caregiver, and three related to system issues, ethics, and practice reflections [70]. Our draft deprescribing competency framework aligns with the prescribing competencies from both the RPS and RCPSC.

To inform the framework, we began with the deprescribing process outlined by Reeve et al., expanding their five-step process to encompass seven general competencies [71]. These include gathering and interpreting a patient’s medication history and clinical information in the context of patient-specific factors, using tools that help identify PIMs, weighing the potential benefit and harm of continuing or deprescribing medications, using shared decision-making to make decisions about deprescribing, communicating deprescribing and monitoring plans, and monitoring progress and outcomes. The seven statements describe the general competencies for consideration by curriculum planners and are expanded upon in Table 1 [1, 69, 70, 72,73,74,75,76,77] with descriptions of the required knowledge and skills. We recognize that the competencies may need to be individualized for different programs, but importantly, they begin the conversation about how to integrate deprescribing competencies into healthcare professional education. We also recognize that many health professional programs are tightly scheduled, and it may seem challenging to determine if or how these competencies might be integrated in a busy program. To facilitate this process, we have included those RCPSC and RPS competencies that align with the deprescribing competencies in Table 1, supporting the approach to co-teach these concepts. We have also provided an example of a process that could be used to assess current curricula for consistencies and gaps (Appendix 1).

Table 1 Proposed entry-to-practice competencies to guide deprescribing curricula for pre-licensure healthcare professional learners in Canada [1, 69, 70, 72,73,74,75,76,77]. All healthcare professional curricula are guided by patient care competencies specific to their profession. The proposed competencies below are built upon, or highlighted from, the foundational professional competencies, specific to deprescribing, and are intended to be applied in collaboration with patients and/or their family/care partners. Both the RCPSC [70] and the RPS [69] prescribing frameworks were reviewed in the development of these competencies (RCPSC, Royal College of Physicians and Surgeons of Canada Prescribing Safely Canada Initiative; RPS, Royal Pharmaceutical Society’s Competency Framework for All Prescribers)
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To make decisions about deprescribing, healthcare professionals must understand a patient’s medication experience. Medication reconciliation can identify medications without a clear/current indication. Explicit tools such as STOPP/START [73] and AGS Beers Criteria® [1] and implicit tools such as the Medication Appropriateness Index [75] can be used to identify potentially inappropriate or unnecessary medications. Reviewing the patient’s clinical conditions, functional status, and laboratory tests can guide decisions regarding medication choice, benefit/harms, dosing, interactions, and contraindications.

A shared decision-making process supports patient and healthcare professional discussions about the balance of potential benefit and harm for each medication [78]. This can elucidate medications that may no longer be appropriate and help prioritize these for deprescribing [79]. Healthcare professionals must be able to elicit patient values and beliefs about their health and their goals of care, and incorporate this information with their clinical knowledge of the medical conditions and medications and the context in which care is being delivered to inform priorities and plan for how deprescribing will take place [80].

Implementing deprescribing requires both technical knowledge and cognitive skills. These include understanding prescription changes, regulatory requirements, and communication/documentation skills. Cognitive skills include the ability to prioritize, think critically, use emotional intelligence for interactions with patients, and work within an interprofessional team.

The following competencies, to be applied in collaboration with the patient and/or their family/care partners, are proposed for deprescribing:

  1. 1.

    Conduct a comprehensive patient medication history

  2. 2.

    Interpret relevant information in the context of desired therapeutics outcomes and goals of care

  3. 3.

    Identify medications that are no longer necessary, may have more harm than benefit, or are otherwise potentially inappropriate

  4. 4.

    Assess the deprescribing potential of each medication by weighing benefits and harms

  5. 5.

    Decide whether deprescribing a medication is appropriate using shared decision-making

  6. 6.

    Design, document, and share a deprescribing and monitoring plan

  7. 7.

    Monitor patient progress and provide support.

Consider Interprofessional Education

Based on their scope of practice, each entry-to-practice curriculum emphasizes different knowledge and skills related to medication use. All learners must have the requisite competencies related to health and evidence-informed practice and demonstrate the ability to develop a therapeutic relationship with the patient, engage them in their care, and work interprofessionally within their scope of practice.

Healthcare professionals in medicine, pharmacy, and nursing identify that they have a clear responsibility in medication management [61]. This includes identifying opportunities for deprescribing, engaging in shared decision-making, implementing the deprescribing plan, and following up on the deprescribing process.

Effective deprescribing leverages each healthcare professional’s strengths and unique perspective on patient care. Teaching deprescribing provides an opportunity for interprofessional education demonstrating how, for example, physicians, pharmacists, nurses, dentists, dieticians, physiotherapists, social workers, and others, can collaborate with patients and family/care partners. It is important to understand how an interprofessional team can function within various healthcare settings to leverage each professional’s expertise and scope of practice to improve medication use and safety.

Education Strategies

Deprescribing can be included early, midway, and later within programs. To understand the prescribing-deprescribing continuum, key concepts should be introduced early and built upon throughout the curriculum in a sequential manner. The competencies (Table 1) in this document focus on the knowledge and skills that learners completing their entry-to-practice degrees should be able to perform successfully. The learning outcomes (Table 2) are more specific and measurable and can be integrated into specific lesson plans or course syllabi. The expected level of competency for deprescribing activities may vary and should be determined by the health professional program, for example, whether a specific competency should be taught at an advanced or intermediate level, depending on the role of that health professional in medication management.

Table 2 Teaching and assessment of knowledge and skills related to deprescribing in pre-licensure healthcare professional curriculum
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Deprescribing content can be taught as a standalone concept/module/course or progressively integrated into various courses throughout the program and included within experiential education. Standalone content may be appropriate for curricula where medication management is not a focus but where learners would benefit from understanding how some patient symptoms may be related to medications and may resolve with deprescribing. In such instances, highlighting their contribution toward reducing medication harm and supporting non-drug interventions is important.

Implementing effective deprescribing requires the application of knowledge regarding biological, pharmaceutical, and social sciences and a broad understanding of medication use behaviors, medication processes, pharmacokinetics, pharmacodynamics, team dynamics, shared decision-making, regulations, and policies. As polypharmacy is highly prevalent in older adults, much of our knowledge about deprescribing is informed by this population. As such, it is logical to include geriatrics courses that teach deprescribing; however, as we have outlined, principles should be introduced early on and carried throughout the curriculum.

Table 2 provides details, where we have applied models for learning frameworks and curriculum design [81, 82] to propose learning outcomes at different levels, examples of teaching and learning activities, and examples of assessment strategies. Ensuring learners have numerous, scaffolded, thoughtful learning and assessment activities throughout their programs, with meaningful interprofessional touchpoints, will support the development of competency in deprescribing.

Introductory/Early Learner

All healthcare professional learners begin to develop professional identity through understanding their scope of practice. At this stage, they require an understanding of the epidemiology of common health conditions and how such conditions may be caused or exacerbated by medications.

Medicine, pharmacy, and nursing programs should introduce learners to patient care and medication use processes, including how decisions related to prescribing and deprescribing are made. Such concepts should be taught in the context of effective communication within a shared decision-making framework. Learners must be able to gather information related to medication use and identify medications that may be inappropriate.

Mid-level Learner

All healthcare professional learners should be introduced to principles of geriatric medicine and made aware of common geriatric syndromes and medication-related problems, including drug interactions and adherence challenges. It is essential to advocate for a patient-centered approach, including the importance of including family/care partners in decision-making.

Approaches to interprofessional practice should be included in all curricula. Using the Canadian Interprofessional Health Collaborative (CIHC) Interprofessional Framework [83] and the domains of interprofessional communication, patient- and family-centered care should be introduced, emphasizing how this can support discussions regarding medication use.

Learners in medicine, pharmacy, and nursing should have specific curriculum requirements relating to geriatrics including common medication-related problems and physiological changes that affect medications with aging. They should be able to elicit a patient’s goals of care and determine if they align with their medications. Education should build on introductory learning to include the application of tools to identify polypharmacy, PIMs, and resources/tools to guide medication decision-making. Learners should be able to describe the deprescribing process, evidence related to both benefits and harms of medications, and evidence supporting deprescribing when available. Discussions of ethical challenges relating to medication problems in older adults, including the ethics of gaps in evidence, should be introduced. Learners should be able to apply deprescribing concepts to a simulated case of a patient with minimal disease burden/complexity.

Advanced Learner

All learners should be able to describe why and how older adults and other groups may be more vulnerable to medication problems and develop an understanding of how to provide care for those with late-stage chronic disease, terminal disease, dementia, and frailty, and those at the end-of-life. Additionally, learners should understand how care is provided in various settings (e.g., long-term care, acute care, outpatient, primary care) and the implications of deprescribing in these contexts, including unique system barriers, processes, and patient needs within different settings.

Medicine, pharmacy and nursing learners should be able to critically assess the levels of evidence, validity, strengths, and weaknesses of various tools used to identify PIMs and deprescribe medications, and determine the appropriate situations for the tools’ application. Learners should be able to prioritize medications for deprescribing and develop and implement a care plan that includes monitoring and support. Learners should be able to approach deprescribing given an integrated case study involving an older adult with complex multimorbid conditions. Complexity factors may also include ethical concerns, family dynamics, cultural differences, special or vulnerable populations. The curriculum should guide learners on how best to advocate for appropriate deprescribing, especially in older adults, and to understand safe medication practices.

Teaching and Assessment Strategies

Each healthcare profession has a unique culture and context for curriculum delivery and assessment, and each program may have different access to resources.

General guidelines for teaching deprescribing include:

  • Introduce deprescribing concepts early and emphasize that deprescribing is a continuum of prescribing

  • Provide education throughout all years of the program using progressively complex cases to enable learners to develop knowledge and skills related to medications and deprescribing

  • Increase the complexity of deprescribing scenarios by introducing different healthcare settings, family/care partners, team members, ethical considerations, and clinical characteristics

  • Structure deprescribing discussions in relation to all therapeutic areas and within curriculum relating to the patient’s social and health system context

  • Plan and integrate deprescribing concepts across interprofessional education programs

  • Incorporate teaching and learning strategies such as didactic, active learning, simulation, and experiential education

General guidelines for the assessment of deprescribing include:

  • Provide learners with both formative and summative feedback regarding deprescribing practice cases and assignments

  • Assess foundational concepts through multiple choice questions or short answers

  • Consider a range of approaches and decisions regarding deprescribing that are supported with rationale and development of care plans

  • Employ Objective Structured Clinical Examinations (OSCE) and Team OSCEs (TOSCE) to assess the application of basic and complex knowledge at different points in the program, from early to advanced levels

  • Integrate deprescribing concepts that can be assessed in other related courses that include communication activities, application of ethical principles, or assessment of evidence

  • Include specific objectives related to prescribing and deprescribing in experiential education/practicum and ensure assessment is conducted by preceptors (e.g., appropriately weighing of potential benefit and harm, communication, documentation, follow-up)

  • Ensure feedback from multiple sources, including patients and family/care partners, simulation facilitators, professors, near peers (same year, same program), senior peers (higher year, same program), and interprofessional team peers

A Call to Action

Deprescribing is best accomplished within an interprofessional practice that is patient-centered and informed by shared decision-making. Based on the seven deprescribing competencies outlined, educators should identify learning objectives to be attained through both uni- and inter-professional education. The specific knowledge and skills taught within programs will be dependent on the perceived gap between the suggested competencies and performance of graduates from the program.

Curricular leaders, national health professional faculty associations, and accrediting bodies must take the following steps, within suggested timeframes, to ensure that learners in medicine, pharmacy, and nursing attain the required competencies in deprescribing and that all healthcare professionals are able to recommend interventions, including non-pharmacological management, that reduce reliance on medications:

In the next year:

  • Examine what needs to happen within your profession, your program, and across interprofessional curricula to ensure graduates are trained to undertake or support deprescribing in their practice

In the next 2 years:

  • Map the curriculum to determine where, when, and how deprescribing competencies are included in current programming, including how they are taught and assessed and identify areas for inclusion

  • Develop a plan to address curricular gaps

  • Create opportunities within curricula to implement deprescribing competencies and determine how these will be taught and assessed

  • Utilize practical tools (Table 3) throughout the curriculum

In the next 4–6 years:

  • Evaluate the core deprescribing competencies of graduates to determine the effectiveness of curricular changes

Annually:

  • Share learnings and outputs (e.g. curricular innovations, continuous professional development opportunities, prescribing and deprescribing competency frameworks) with the Canadian Deprescribing Network (info@deprescribingnetworks.ca) to facilitate sharing, networking and collaboration across Canada.

Table 3 Deprescribing Resources Toolkit
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Conclusion

Integrating deprescribing competencies in healthcare curricula requires an intentional and structured approach across all years of the program, focusing on interprofessional collaboration. Learning activities should be active and practical, progressing from early to advanced learner skills and include integration of deprescribing during experiential education. As appropriate, the guidelines for curriculum design and learner assessments in deprescribing, emphasized within a geriatric context, can be integrated throughout all therapeutic content/courses. The process of preparing healthcare professionals to be confident deprescribers relies on a solid foundation within the pre-licensure curriculum. Building this foundation is essential to ensure healthcare professionals are able to deprescribe safely to minimize the personal and societal costs of medication-related harm.