Community pharmacists as catalysts for deprescribing: An exploratory study using quality improvement processes

Abstract

Background:

There is growing international emphasis on deprescribing, involving the monitored reduction or stopping of medications that are no longer needed or that cause more harm than benefits, especially for the elderly. Community pharmacists are well positioned to partner with patients and their other health care providers in facilitating deprescribing activities.

Objective:

To build community pharmacists’ capacity to integrate deprescribing into their daily practices through training and workflow strategies.

Methods:

This study used an exploratory mixed-methods (primarily qualitative) design. Staff at 4 Ontario pharmacies were trained to use deprescribing guidelines. Qualitative data were collected through field observations, notes from advisory group meetings and documented Plan-Do-Study-Act (PDSA) plans. Quantitative data were derived from process and output measures reported by the pharmacies. Iterative PDSA cycles allowed the project team to appraise and accelerate process improvements over time and to summarize findings on facilitators, barriers and the adaptation of processes.

Results:

All 4 pharmacies identified individual and common goals related to deprescribing; however, drugs targeted and use of professional services to identify and address deprescribing opportunities varied. Each demonstrated that deprescribing activities could be integrated into daily practice and workflow. Common themes characterized approaches taken by each pharmacy: (1) processes used for capacity building among staff to identify patients for possible deprescribing, (2) approaches for preliminary interactions with patients, (3) in-depth medication reviews and (4) follow-up and monitoring. Approaches changed over time.

Conclusion:

Deprescribing appears to be feasible in community pharmacies. Data derived to populate a business model canvas informs the development of an in-depth business model for deprescribing. Can Pharm J (Ott) 2019;152:xx-xx.

Introduction

Deprescribing is the monitored reduction or stopping of medications that are no longer needed or that cause more harm than benefit. It is a promising approach to mitigate the growing problem of polypharmacy. This is especially relevant for older adults, for whom adverse effects and drug interactions often lead to morbidity (including falls and cognitive decline), hospitalization and even death.^1-7

Knowledge into Practice.

• Community pharmacists are uniquely well positioned to identify opportunities for deprescribing and to monitor patients through the process.

• The results of this study emphasize that deprescribing activities are feasible within the community pharmacy workflow.

• A business model canvas can be populated to plan an individualized pharmacy business model to incorporate deprescribing practices as part of routine care.

Mise En Pratique Des Connaissances.

• Les pharmaciens communautaires sont très bien placés pour cerner les occasions de déprescription et assurer le suivi des patients pendant le processus.

• Les résultats de la présente étude soulignent le fait qu’il est possible d’intégrer des activités de déprescription au déroulement des activités des pharmacies communautaires.

• On peut utiliser un canevas de modèle d’affaires pour planifier le modèle d’affaires d’une pharmacie afin d’intégrer les pratiques de déprescription aux soins réguliers.

In previous work, the Bruyère Deprescribing Guidelines Research Team developed evidence-based deprescribing guidelines for proton pump inhibitors (PPIs), benzodiazepine receptor agonists (BZRAs), antipsychotics (APs) and antihyperglycemics (AHGs) and collaborated with Australian researchers on a fifth deprescribing guideline for acetylcholinesterase inhibitors and memantine.^8-12 Use of the guidelines has been associated with increased self-efficacy for deprescribing, as well as reduction in PPI use.^13,14

Experience with guideline implementation suggests that efforts can be successful when pharmacists conduct medication reviews as part of interprofessional teams. This is consistent with studies demonstrating the positive impact of pharmacist-conducted medication reviews on reduction in medication use and improvement of health outcomes of older patients.^15-19

The Bruyère team contends that community pharmacists are uniquely positioned to champion the use of the deprescribing guidelines, yet many have voiced the need for support to integrate deprescribing into practice. This study sought to examine the implementation of deprescribing guidelines in community pharmacy contexts. It was hypothesized that, when empowered by training, tools and strategies based on the deprescribing guidelines and supported by an engagement process with iterative Plan-Do-Study-Act (PDSA) cycles,²⁰ community pharmacists would be able to effectively engage in deprescribing and that this would ultimately lead to identifying important elements of a business model canvas.

Methods

The implementation of deprescribing guidelines was examined in 4 community pharmacies in Ontario using an exploratory, mixed-methods (primarily qualitative plus quantitative. i.e., QUAL, quan) approach.²¹ To build capacity to integrate deprescribing into their practice, each site received individualized support, educational resources, tools and videos. The latter included a project orientation video created to ensure a systematic approach to providing education to each site. An Advisory Group was formed to provide direction on deprescribing workflow processes. Members represented the Ontario Pharmacy Evidence Network Knowledge User Advisory Committee, national health insurance payor organizations and pharmacy provider groups, pharmacists from each of the 4 pharmacies and study co-investigators.

To understand the deprescribing workflow and site characteristics, an approach informed by ethnography,²² featuring systematic field observations of pharmacy activities, was employed. Two trained, nonparticipant observers collected field notes regarding physical space, pharmacy layout, staff composition and dynamics, workflow and daily routines. The trained observers completed 2 to 3 observation periods at each pharmacy and maintained field notes documenting their observations and experiences. This approach allowed for a detailed “thick” description of activities and opportunities, more so than what interviews alone would allow for, as the latter can provide only what the subject recalls or chooses to say.²³ Patients using pharmacy services during the observation period were assured that their names and identifying information were not being recorded, and the use of a nonparticipant observer limited the impact to the pharmacist-patient interactions. The participating pharmacies selected their own implementation strategies and activities for the use of deprescribing guidelines. Strategies and approaches varied by site; iterative PDSA cycles²⁰ were conducted by each pharmacy to test how interventions were implemented in these different practice contexts. All pharmacies used a common PDSA template, which recorded the features of each implementation strategy. The PDSA cycles allowed the research team to appraise process improvements over time and to summarize key findings on facilitators, barriers and the adaptation of processes. Through iterative observation periods in each pharmacy and discussion of findings with the Advisory Group, workflow strategies and processes were honed over time. Regular meetings with the Advisory Group and research team facilitated an engagement process that provided motivation and helped build capacity for implementation.

The sequence of Advisory Group meetings, PDSA cycles and data analysis activities is illustrated in Appendix 1 (all appendices are available in the online version of the article). The study was approved by research ethics boards at the Bruyère Research Institute, Concordia University and University of Toronto.

The research team conducted a rapid analysis following each observation period, the results of which were presented to the Advisory Group and considered by each pharmacy for its next cycle of activities. This analysis was carried out by at least 3 researchers who reviewed the data and identified highlights and themes and who collectively developed materials to present to the Advisory Group.

To quantify deprescribing opportunities (e.g., prescription statistics), actions (e.g., process measures) and outputs (e.g., pharmaceutical opinions generated, educational materials and resources created by the pharmacy partners), the team asked pharmacies to provide baseline information (e.g., average prescription volumes, hours, pharmacist and technician staffing, services provided, provision of student training), a record of project-related activities initiated by their team and outcomes identified (including materials created in-house such as communication templates for prescribers), as well as the cost of materials developed or advertising undertaken. To allow flexibility in implementation, the team did not require this information to be provided in a standard manner.

The complete data set was analyzed by a qualitative research consultant using a combination of deductive (informed by the rapid analysis results) and inductive coding of field notes, minutes from Advisory Group meetings and PDSA plans. This informed the drafting of a business model canvas (Figure 1) that was then refined by members of the Advisory Group.²⁴ The team envisages this canvas to help make explicit the conceptual link between strategy, business organization and systems.

Figure 1.

Business model canvas: community pharmacists as catalysts for deprescribing

Results

Below, the approaches used and the outcomes documented within the 4 pharmacies are described, followed by a summary of the process steps that were similar across all 4.

The pharmacy sites represented a mix of chain and independent pharmacies, 2 in Toronto and 2 in Ottawa (Appendix 2). The pharmacies offered a range of clinical services (e.g., MedsChecks, pharmaceutical opinions [PO], compounding, compliance packaging, immunizations, point-of-care testing, travel medicine, smoking cessation), and most provided student training.

Each site approached the implementation of deprescribing guidelines differently. Their experiences are described below, and details of their deprescribing interventions and outcomes are reported in Table 1.

Table 1.

Deprescribing interventions and outcomes (as reported by pharmacies)

Pharmacy 1 • Eight recommendations regarding PPIs (reduced frequency, dose lowering or change to on-demand) by the pharmacist (with 6 changes made; 1 recommendation was declined by the physician and 1 for which the physician conducted an assessment but did not make a change) • Two recommendations regarding BZRA, 2 with 1 patient agreeing not to use the newly prescribed BZRA and 1 taper declined by the physician • Four recommendations for AHG deprescribing (glyburide to gliclazide), of which 3 were accepted and 1 was declined by the physician • Fourteen attempts made to initiate deprescribing, of which 10 were considered successful (guideline recommendation followed) • Patient outcomes were documented for 3 PPI patients who noted no return in heartburn symptoms

Pharmacy 2 • Sixty-seven deprescribing interactions, 39% (n = 26) of which were current patients and 61% (n = 41) of which were new patients who self-identified as a result of advertising (n = 40) • Thirty-seven inquiries (calls or walk-ins) resulting from roadside sign, 1 from newspaper notice and 2 from website • Most interactions were for PPIs (62), with small numbers for BZRA (2), AHG (1) and AP (1) and (1) not documented • Initial interactions resulted in 8 patients scheduling (or expressing clear intent to schedule) a free 15-minute consultation by appointment with the pharmacist. Of those who had a free 15-minute pharmacist consultation, 3 booked and paid for an in-depth consultation ($200/hour); all 3 patients had a PPI successfully deprescribed • Seven MedsChecks were conducted, all focused on PPI deprescribing (6 with current patients flagged by dispensary staff and 1 with a walk-in patient); of these, 4 patients successfully stopped their PPI, 1 stopped but had their PPI restarted in hospital, 1 was not a candidate for deprescribing and 1 had an unknown outcome • Seven POs (along with copies of relevant deprescribing algorithm) generated (4 resulting from PPI-focused MedsChecks and 3 resulting from other interactions: 1 BZRA, 1 AHG and 1 PPI) and sent to prescribers; no reply in 3 cases, no change for 3 others and 1 had no outcome reported. Despite lack of PO response, the 4 patients who had PPI deprescribing recommended discussed it with their physicians and successfully reduced or stopped their PPI with supervision and monitoring by the pharmacist • Ten documented retail sales recorded (for patients on PPIs, products such as magnesium or gastrointestinal healing supplements)

Pharmacy 3 • Twenty-seven deprescribing events recorded • One pharmacist documented 12 POs for PPIs (9 accepted and 3 declined), 1 for a BZRA (accepted), 2 for cholesterol medications (accepted), 2 for a blood thinner (1 accepted and 1 with patient returning to the clinic for assessment), 1 for an antihypertensive (accepted) and 1 for an antibiotic (accepted); of the PO sent, 15 were accepted by the prescriber and implemented • This pharmacist also recalled 4 PPI and 2 BZRA deprescribing recommendations made during patient counselling, but details were not recorded • The second pharmacist recalled 5 BZRA cases (1 successfully tapered, then restarted; 3 with a taper initiated but returned to previous dose, 1 successfully tapered) and 2 PPI cases (both successfully stopped)

Pharmacy 4 • Fifty-nine patients identified (from database) as potentially eligible for deprescribing, but many were not candidates because of ongoing indication for the medication, a history of rebound and failure with other treatment options, reluctance to try or an expressed preference to discuss their medications with the physicians themselves rather than have the pharmacist contact the prescriber with a plan • Twenty-three MedsChecks were conducted (of 33 scheduled, 9 did not come to the pharmacy for the appointment), generating 15 POs, which resulted in 7 successful tapers: 5 for PPIs and 2 for BZRAs • Five POs were sent to prescribers but declined; 3 were sent without a prescriber response • Eight patients did not want to stop medication, and no POs were sent

PPI, proton pump inhibitor; BZRA, benzodiazepine receptor agonists; AHG, antihyperglycemics; AP, antipsychotic; PO, pharmaceutical opinion.

Pharmacy 1

Pharmacy 1 explored use of the deprescribing guidelines through medication reviews completed with patients of both retirement homes to whom they provided service and current community-dwelling patients seeking refills. Their PDSA objectives focused on educating staff and health care providers (HCPs); discussing deprescribing with patients taking PPIs, APs, BZRAs or AHGs; learning about stakeholder perceptions of deprescribing; and finding ways to incorporate deprescribing into care routines.

Ultimately, this pharmacy targeted patients prescribed a PPI, BZRA or AHG medication. They educated staff, informed local HCPs about the deprescribing initiative and created a binder of resources, including patient handouts and prefilled forms for the different drugs to facilitate communication with prescribers. Throughout the initiative, this pharmacy realized that despite having an initial PDSA plan, unanticipated barriers to deprescribing were experienced, including a lower number of completed medication reviews, patients in retirement homes who were unaware of their medication indications, mixed reception and interest in deprescribing from patients, some prescribers who were unresponsive to POs and the need for more time for deprescribing activities than initially expected. In terms of communication with HCPs, they found that prescribers they engaged with were typically receptive but often unresponsive; they could be categorized into those who responded right away and made a therapeutic choice (to agree or reject the PO) and those who did not respond or declined without considering the recommendation. During reflection on the process, this team noted that they learned how to communicate deprescribing to both HCPs and patients. They also noted that deprescribing discussions were best initiated in person and that deprescribing had to be conceptualized as part of routine practice rather than as an extra service provided when they “had time” to do so.

Pharmacy 2

Pharmacy 2 chose to explore deprescribing by involving their entire staff team (from front store through to the dispensary and clinical team) and focusing on strategic patient education and advertising initiatives to new and current patients. Their PDSA plans focused on meeting with and educating patients taking PPIs, BZRAs, APs or AHGs; raising awareness of polypharmacy; determining the financial feasibility of deprescribing services within pharmacies; understanding patient motivations; and solving the health problems that give rise to polypharmacy.

Throughout the study period, this pharmacy adapted to meet practice realities. They encountered barriers regarding patient motivation for deprescribing, physician nonresponse to faxed POs and the challenge of collecting deprescribing data. Although the team found the resources and supports useful, deprescribing activities suffered when pharmacists experienced competing demands on their time. To address this issue, they determined staff overlap would allow for scheduling completion of MedsChecks and follow-up with patients and prescribers, and so, late in the study period, they hired a new pharmacist to work 3 days/week to focus on clinical activities including deprescribing. The owner of the pharmacy was described by staff as “exceptionally motivated,” and they recognized that owner or company buy-in is key to successful implementation of this type of activity.

Advertising initiatives included a notice in the community newspaper (for $260; Appendix 3), a roadside sign (Appendix 4) and signs at the entrance of the pharmacy. They also posted deprescribing information on their website and created an email address specific to deprescribing to handle queries. They hosted a webinar about deprescribing that was tailored to a public audience (cost of pharmacist time only as they already provided webinars for the public routinely).

Staff documented deprescribing opportunities in terms of initial staff interactions, free 15-minute consultations with a pharmacist, paid in-depth consultations with a pharmacist, routine MedsChecks, PO and related retail sales.

Initial interactions about deprescribing with the “walk-in” patients were conducted by both front shop staff and dispensary staff and were approximately 5 to 15 minutes in length, often with brochures or written information provided to patients to review (including for situations in which patients were unaware of the PPI indication in particular).

Pharmacy 3

Pharmacy 3 chose to explore deprescribing during routine activities with existing patients. Their PDSA plans focused on identifying patients taking BZRAs or PPIs who could benefit from deprescribing, discussing deprescribing with these patients and then starting the deprescribing process.

Pharmacists examined opportunities for deprescribing during daily activities (e.g., at refills) and patient interactions; while they did not always track exact numbers of deprescribing interventions, they felt that approximately one-quarter of these opportunities arose during routine MedsChecks. Additional opportunities arose during patient counselling activities. As part of their learning experience, students assisted with documentation and follow-up (e.g., contacting physicians regarding nonresponses to PO). Engaging students in deprescribing initiatives, however, resulted in the need for ongoing training due to turnover. The site recognized the need for consistent approaches to training new staff and students and suggested that an online module might be a solution.

Each intervention required an average of 10 to 15 minutes of discussion with the patient and an additional 5 to 10 minutes to follow-up to implement changes. Once a week, a second pharmacist provided 7 hours of clinical services, including deprescribing. No other expenses were felt to be incurred, although it was recognized that additional pharmacist time was needed.

Pharmacy 4

Pharmacy 4 initially sought to identify patients for deprescribing through routine MedsChecks. Their PDSA plan focused on identifying relevant patients through MedsChecks, particularly those taking PPIs, speaking with these patients and starting the deprescribing process.

The pharmacist identified as the project lead at this site changed between cycles, which resulted in new actions and methods of identifying patients. While pharmacists were initially prompted (through the use of a wall poster) to focus on PPI use during MedsChecks, the focus shifted to generating database reports and to targeting patients with long-term use of blister packs. Initiating deprescribing conversations with patients was more challenging than anticipated because of what was felt to be a limited understanding of the pharmacist’s role in medication management. With help from a student, they developed a structured plan to identify patients and incorporate deprescribing into scheduled clinic days. Discussion regarding PPI deprescribing was felt to be easier than BZRA deprescribing. A formal data collection method was implemented to track progress, and it was identified that although vigilance in monitoring patients was improved, a method to incorporate patient follow-up into practice was needed. Regularly scheduled staff meetings maintained enthusiasm. Pharmacists felt patient relationships were strengthened even when deprescribing was not the final outcome.

Commonalities

All 4 pharmacies demonstrated that deprescribing activities could be integrated into daily practice and workflow; analysis distilled a series of 4 similar steps across sites that outline a potential deprescribing process. These are outlined in Table 2, along with examples.

Table 2.

Overview of the common deprescribing processes

Step 1: Capacity building and processes to engage patients in deprescribing
Activities and processes aimed at identifying and engaging patients in a deprescribing dialogue varied across sites but included a combination of the following: • Educating pharmacists, pharmacy technicians, pharmacy staff and students to ensure familiarity with the deprescribing guidelines and processes • Conducting database reviews (often done by students) to identify potential patients based on medication profiles • Identifying patients during walk-ins, MedsChecks, renewals and refill calls • Initiating conversations with patients when picking up their medications • Engaging in advertising and outreach measures (online resources, newspaper articles, signs and billboards) to raise patient awareness regarding deprescribing practices
Step 2: Preliminary interactions
Preliminary interactions with patients typically occurred with the pharmacy support staff (e.g., technicians, students, front store). These initial engagement interactions were used to triage patients, answer questions, validate concerns, provide information (pamphlet, handouts, verbal guidance) and introduce patients to the pharmacist for in-depth discussions (when feasible). Potential patients for deprescribing were typically self-identified or pharmacy-identified. • Self-identified patients presenting to pharmacy with questions regarding deprescribing (i.e., “My husband has been on a PPI for a year and I saw your sign that this might be harmful, and I want to know more.”) • Pharmacy-identified: Patients approached while in store (medication pickups, renewals, refills) or contacted by phone based on database reviews, to initiate dialogue about length of use, symptoms and triggers, willingness to discuss deprescribing and potential to come in for a medication review.
Step 3: Detailed interactions with the pharmacist
Pharmacist interactions involved scheduled and unscheduled medication reviews and consultations. During medication reviews (MedsCheck, MedsCheck for Diabetes), pharmacists were observed to: • Verify chronic medical conditions, allergies and overall health status • Review and discuss the proper use of all medications, including nonprescription products, vitamins and natural products • Assess for opportunities to deprescribe and aim to resolve any identified drug therapy issues • Assess health goals, lifestyle choices and values • Provide education and support about how to obtain the best results from their medications • Document the interaction (pharmacist assessment, treatment plan, record of care, monitoring results) and consult prescribers/prepare a PO as necessary
Step 4: Follow-up and monitoring
Pharmacists (at some sites, students and other support staff) followed up with continued attempts to contact HCPs and to monitor patient outcome. Activities included: • Faxing POs to physicians, with repeated faxes sent as required • Telephone follow-ups in case of delayed or nonresponses from HCP (at select sites, students completed the HCP follow-up step for delayed or nonresponses) • Tracking follow-ups, interactions and outcomes for internal documentation

PPI, proton pump inhibitor; PO, pharmaceutical opinion; HCP, health care provider.

Several barriers and facilitators to the implementation and sustainability of deprescribing practices were identified across all 4 practice sites (Table 3). General implementation tips are given in Box 1.

Table 3.

Barriers and facilitators to deprescribing activities

Barriers to sustainability

Facilitators of sustainability

• Competing workload demands and time • Staff turnover and new staff training • Communication delays and lack of response from health care providers about pharmaceutical opinions • Patient uncertain or resistant to change • Deliveries and use of multiple pharmacies for dispensing medications • Duplication of documentation • Inadequate compensation models for the time required in deprescribing events • Workspace limitations for deprescribing discussions

• Supportive staff and students who were motivated regarding deprescribing and willing to share the workload • Onsite educational initiatives and employing a collaborative team approach • Enhancing patients’ awareness and education regarding the risks and options to reassess • Standard templates to reduce time spent on each pharmaceutical opinion (Appendix 5) • Approaches to draw patients into the pharmacy and having all staff trained to field questions

Box 1 Implementation tips.

• Work as a pharmacy team to decide which drug(s) should be the focus of deprescribing efforts and how to identify patients within the pharmacy workflow who may benefit from deprescribing.

• Set a goal for the number of patients to approach within a specific time frame for deprescribing conversations. Revisit the goal and strategies used regularly.

• If a strategy to initiate deprescribing activities is not working, then change to another strategy.

• Linking deprescribing efforts to funded professional services may be a useful strategy.

• Use readily available deprescribing educational materials for patients and staff (https://deprescribing.org/).

• Pharmacy students can be helpful in initiating or following up on deprescribing conversations with patients—these opportunities serves as an excellent student learning experience.

Business model canvas

The business canvas acts as a start-up template for developing a business model (Figure 1). For the purposes of this article, it is a simplified representation of the complex process of deprescribing in a community pharmacy context. It demonstrates how the pieces of a business concept fit together; however, unlike a full business model, it does not include strategies and costing to forecast the financial impact of implementing various strategies.

Discussion

In this study, 4 pharmacy sites identified individual and common goals and developed unique workflow models for deprescribing. The sites were diverse and distinctive, which strengthened awareness that the feasibility and results of implementing deprescribing practices are dependent on individual pharmacy contexts. The drugs targeted and activities to identify opportunities for deprescribing were not the same across pharmacies. In most cases, approaches changed over time as experience with deprescribing activities was gained. There was clear variability in practice and no “one-size-fits-all” approach to implementing change. Each pharmacy used the project materials and processes differently; however, each pharmacy was able to effectively implement deprescribing in their daily workflow. This underscores that deprescribing is feasible at the community pharmacy level for those interested in this type of practice.

This study conceptualized deprescribing as a collaborative social process that engaged pharmacists, patients, payors, students and business managers at various stages of the deprescribing process. The mixed-methods evaluation we conducted allowed us greater insight into the opportunities for and actions taken to facilitate deprescribing. This study also enriched the depth of our understanding regarding the “why and how” behind successful deprescribing initiatives through the identification of facilitators and barriers as well as a common 4-stage process that appeared related to success.

The methodological decision to employ iterative PDSA cycles that were analyzed and interpreted by the study team and discussed by the Advisory Group improved the feasibility, efficiency and adaptability of processes and tools used to encourage deprescribing activities in the pharmacies. This approach thus incorporated a process of social learning wherein participants defined and shared their goals, monitored their progress and problem-solved together, and this allowed us to identify the factors important to integrating deprescribing practices in a sustainable fashion.

From the review of PDSA cycles, we noted that the initial plans proposed by the pharmacies changed over time in response to practice realities. Shifting to in-person conversations versus communication over the phone, conceptualizing deprescribing as part of routine practice versus an “add-on,” developing structured plans for deprescribing on clinic days and hiring an additional pharmacist for overlap are some examples of changes made from the initial plans. The idea that implementation plans will evolve and be revised as change agents encounter barriers and facilitators within the specific social context of a busy pharmacy is consistent with the intentions of the PDSA approach and with the change process advocated by most organization development practitioners. This allowed us to appreciate the importance of flexibility in planning and goal setting and the importance of remaining adaptable to the practice context.

These results also lead us to consider whether our use of a reflective learning process contributed to successful outcomes. Participating pharmacies were able to use the PDSA template to develop, finalize and revise their plans. The process called for the monitoring of progress at specified time points and the sharing of results across pharmacy sites as part of the Advisory Group meetings, and this created a forum for discussion and problem solving. Future research could consider whether the use of reflective and collaborative implementation processes enhances goal achievement.

Over the course of approximately 5 months, each pharmacy identified many opportunities for deprescribing, excluded patients for a variety of reasons, provided recommendations and was able to successfully apply the deprescribing guidelines to a small proportion with variable response from patients and prescribers. This demonstrated that successful efforts to help patients with deprescribing were feasible, although it remains to be seen whether the time put into these efforts can be successfully accommodated on a widespread basis in community pharmacy (Box 1).

The research team intentionally did not direct pharmacy staff to capture demographic metrics, intervention or outcome data in a standardized way, and thus it is challenging to compare the quantitative opportunities and impact of deprescribing across sites. Some pharmacy sites maintained detailed logs regarding interactions, indications, staffing and time spent on deprescribing encounters, whereas others used more ad hoc approaches involving data collection on Post-It notes during interactions. However, these data supported our development of the business model canvas that focuses on process implementation with room for adding cost structures and revenue streams. This canvas can be used to develop an in-depth business model for deprescribing. Individual pharmacies can populate the model for their own practices with their prescription numbers/types, patient encounters and remuneration opportunities. Going forward, the research team plans to define key data measures and indicators and develop a data collection plan for consistent metrics (and including interim audits for data quality) to allow meaningful comparison across sites and estimation of impact. A team member with expertise in health economics will be sought to help plan for, analyze and develop a novel and testable business model for deprescribing in community contexts.

The findings from this project lay the foundation for the next phases of this work: a larger demonstration study to examine reach, adoption and implementation of deprescribing strategies within community pharmacies and ultimately a randomized controlled trial of community pharmacy–based deprescribing interventions that explores patient and health system outcomes, including related cost-savings.