Clinical Integration and Evaluation of the STrategic Optimization of Prescription Medication Use in Patients on HemoDialysis (STOPMed-HD) Intervention

Abstract

Background:

People undergoing hemodialysis (HD) take an average of 12 medications daily, with 93% prescribed at least one potentially inappropriate medication or dose. Polypharmacy is commonly defined as taking 5 or more medications per day; however, it can also refer to the use of inappropriate medication choices and doses. Polypharmacy can lead to serious health consequences, including drug-drug interactions, falls, and hospitalizations. Deprescribing, the process of stopping or gradually reducing the dose of a medication that may be causing harm or offers no benefit, can reduce polypharmacy among older adults. However, little research focuses on deprescribing in the HD population, and few tools exist to support deprescribing in HD. To address this gap, we developed and validated the STrategic Optimization of Medication Use in Patients on HemoDialysis (STOPMed-HD) intervention, a deprescribing toolkit which includes clinician-focused algorithms, monitoring forms, and evidence tables, and patient-facing information bulletins and videos. Co-developed with clinicians and patients, the toolkit reflects patient priorities and aligns with their deprescribing goals. This report describes the implementation and evaluation strategy of the STOPMed-HD intervention at 4 HD sites across Canada, and presents insights into barriers, facilitators, and key considerations for implementation.

Knowledge mobilization and implementation methods:

Our knowledge mobilization and implementation strategy involves a collaborative approach to implement the evidence-based deprescribing toolkit. Our strategy prioritizes engagement with several key partners, including patients and clinicians, to support implementation and foster a culture of deprescribing within HD units across Canada. Clinician buy-in at participating sites was established during toolkit development, and we continue to support clinicians throughout implementation at their respective HD units. Diverse patient partners have been actively involved since the inception of the study, and ongoing patient engagement remains central. To explore facilitators and barriers to uptake, we conducted interviews with patients and clinicians who participated in the 6-month deprescribing intervention at the Toronto site. Interviews at other sites will be completed in the coming months. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework guided our data collection and analysis approach.

Key findings and implementation considerations:

The 6-month deprescribing intervention has been implemented in Toronto, ON; Halifax, NS; Calgary, AB; and Victoria, BC. This report includes key barriers and facilitators identified from the Toronto site. Patient-level barriers include fear of withdrawal, medication dependence, disengagement, and lack of follow-up support, while facilitators include clear messaging about deprescribing and regular monitoring and follow-up. Clinician-level barriers involve time constraints and unclear deprescribing roles and responsibilities among the care team. Barriers faced by facilitators include a lack of evidence-based deprescribing tools, integration of deprescribing into routine practice, a deprescribing champion, and multidisciplinary collaboration. System-level challenges include inadequate resources, fragmented electronic medical record systems, and a need for further research on deprescribing outcomes in the HD population. Potential cost savings and sharing learnings across HD care teams are additional facilitators.

Future directions:

This study demonstrates the potential of a structured, evidence-informed deprescribing approach to enhance patient safety, reduce medication burden, support shared decision-making, and promote team-based medication management in HD. Challenges to sustainability and rollout remain, and further research is needed to identify scalable, sustainable strategies that support long-term success of deprescribing across diverse HD settings.

Keywords

deprescribing hemodialysis medication management implementation evaluation

Background Information

People who are on hemodialysis (HD) take an average of 12 medications per day,^1
-3 and it is estimated that 93% of these individuals are prescribed at least one potentially inappropriate medication.⁴ Polypharmacy is commonly defined as taking 5 or more medications per day; however, it can also refer to the use of inappropriate medication choices and doses.^5,6 Several factors contribute to polypharmacy in people receiving HD, including the presence of multiple comorbidities (eg, hypertension, diabetes, cardiovascular disease) requiring long-term medication use,^1,7,8 frequent health care visits, and interaction with multiple health care providers.^9,10 Polypharmacy is associated with an increased risk of adverse drug reactions, drug-drug interactions, medication nonadherence, hospitalizations, and increased health care costs.^11
-15

One approach to reducing the risk of polypharmacy and improving patient outcomes is deprescribing, which is the planned and supervised process of stopping or gradually reducing the dose of a medication that may be causing harm or is no longer providing benefit.¹⁶ Deprescribing involves a comprehensive medication review to identify potentially inappropriate medications, collaborating with patients to determine which medications can be safely discontinued or reduced, and outlining a plan to monitor the patient’s health throughout the process.^17,18 In HD settings, deprescribing is typically a multidisciplinary effort involving pharmacists, kidney doctors, nurses, and primary care physicians.^19,20 Evidence shows that deprescribing not only improves patient outcomes and quality of life,²¹ but also reduces health care costs by preventing adverse events associated with polypharmacy, including increased morbidity and hospitalizations.²²

While deprescribing has been shown to be an effective strategy to reduce polypharmacy among older adults,^23
-32 little research has focused on deprescribing in individuals receiving HD.^17,21,33 Existing deprescribing tools are not tailored to the unique needs of this population, as they lack medication- and dose-specific guidance and provide insufficient parameters for safety monitoring.²⁷ Patients’ priorities include taking medications where the benefits outweigh the risks and align with their clinical condition and goals of care.³⁴ They also report a need to understand the appropriateness, safety, and processes of medication discontinuation to feel comfortable with deprescribing.⁹ However, current deprescribing tools fail to consider patient values and preferences.^17,25,28,31 Thus, there remains a need to generate evidence demonstrating how a patient-centered deprescribing approach can improve outcomes in people receiving HD.

Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is a national patient-oriented research network that works in partnership with patients throughout all stages of its research projects. At the network’s inception, reducing polypharmacy was identified as a key research priority by patient partners on HD, prompting the development of a deprescribing toolkit specific to the HD population. “The STrategic Optimization of Prescription Medication Use in Patients on HemoDialysis (STOPMed-HD) study generates insights for optimizing medication use in people receiving HD, through the implementation of an evidence-based, structured, and collaborative deprescribing process that includes using a deprescribing toolkit”. This report provides an overview of the STOPMed-HD implementation and evaluation approach at 4 HD sites across Canada, and includes reflections on preliminary findings, as well as identified challenges and opportunities for expansion.

Deprescribing Toolkit and Resource Development

In the first phase of the STOPMed-HD study, we developed resources to educate and support health care providers and patients in making informed decisions around deprescribing medications. With input from 45 clinicians (nurses, nurse practitioners, kidney pharmacists, and kidney doctors)³⁵ and 105 patients³⁶ across Canada, we developed and validated a deprescribing toolkit designed specifically for people receiving HD.³⁵ Previous research identified 12 of the most commonly prescribed medications or medication classes for patients on HD,¹⁰ and the STOPMed-HD team established consensus on “study medications” of focus for the deprescribing toolkit: alpha-1 blockers, benzodiazepines and z-medications (ie, zopiclone), gabapentinoids, loop diuretics, prokinetic agents (ie, metoclopramide), proton pump inhibitors, quinines, statins, and urate-lowering agents.^9,10 The toolkit includes evidence-based guidance to help clinicians identify which of these study medications may be safely deprescribed in people receiving HD. As patient safety, individual preferences, and well-being are central to the co-design and goals of this intervention, we also created and validated patient-facing information bulletins and videos explaining the benefits and risks of deprescribing.³⁶

Last, we developed a deprescribing process that demonstrates how to use the toolkit in a clinical setting (Figure 1). This step-by-step process can be adopted by clinicians at other HD sites who are seeking to implement the deprescribing toolkit in their practice. Evidence suggests that identifying a champion to spearhead deprescribing initiatives may promote successful outcomes.^37,38 Given their expertise in medication reviews and reconciliation, pharmacists are emerging as leaders in deprescribing and are therefore well positioned to champion these efforts.^17,37,39
-44 However, sites can adapt based on their available resources and personnel. For example, in HD settings without an available pharmacist to serve as the champion for deprescribing, a nurse, nurse practitioner, or kidney doctor could assume this role to drive awareness and implementation.

Figure 1.

Deprescribing process.

To further support patient education and promote patient-centered deprescribing, we developed 2 patient-facing videos. The first video describes medication management and deprescribing. This video was co-created with patients and clinicians in the outpatient HD unit at Toronto General Hospital, University Health Network (TGH-UHN) in Toronto, Canada, and centers the voices of diverse patients. The second video provides an overview of deprescribing in HD, including discussion of risks, benefits, and what patients can expect after discontinuing or tapering a medication. We also created patient-friendly 1-page summaries highlighting patient and clinician experiences and perspectives from the 6-month deprescribing intervention at TGH-UHN. All materials, including the toolkit, are available on the STOPMed-HD website (www.stopmedhd.ca), which we actively promote through our partners, including researchers, clinicians, and patients, and at conferences (eg, Can-SOLVE CKD, Ontario Renal Network).

Knowledge Mobilization and Implementation Methods: Applying the Can-SOLVE CKD Pathway to Implementation

Can-SOLVE CKD developed a Pathway to Implementation⁴⁵ designed to serve as a framework for project teams implementing evidence-based health interventions. This 6-step guide consists of the following: step 1: Creating Awareness and Interest; step 2: Readiness Assessment; step 3: Establishing the Implementation Team; step 4: Project Launch; step 5: Implementation, Monitoring, and Evaluation; and step 6: Sustainability. To date, the STOPMed-HD study is on step 5 and step 6 of the Pathway, with the deprescribing intervention complete at recruitment sites in Toronto, ON, and Halifax, NS, and nearly complete in Calgary, AB, and Victoria, BC. The following sections outline our knowledge mobilization and implementation methods for each of the 6 steps of the Pathway to Implementation. The first subsection covers steps 1 to 3, whereas the second subsection discusses steps 4 to 6.

Steps 1 to 3 (Creating Awareness, Assessing Readiness, and Establishing the Team)

Our implementation and knowledge mobilization strategy involves collaborating with a wide range of partners, including patients, clinicians, researchers, and policymakers, to raise awareness, support implementation, and foster a culture of deprescribing in HD units.

Clinician engagement

Achieving clinician buy-in from the entire multidisciplinary HD team, including pharmacists, nurse practitioners, medical specialists, and primary care physicians, is essential for the successful implementation of deprescribing initiatives.¹⁸ We established buy-in early in the process by involving clinicians in the co-design and validation of the deprescribing toolkit. For example, pharmacists across several HD sites met to discuss the consequences of polypharmacy in dialysis settings and assessed patterns of medication use in HD centers across Canada.^9,10 Clinicians’ participation in the development and validation process ensured the toolkit was evidence-based, practical, and aligned with existing workflows, and many expressed interest in using the toolkit within their own HD units. We further achieved clinician buy-in by prioritizing ongoing engagement with clinical partners at participating sites to address emerging challenges and collaboratively identify strategies to enhance the deprescribing process at their respective sites.

Implementation team

The initial deprescribing intervention was led by clinicians at TGH-UHN. To support implementation across Canada, we identified 3 additional HD sites to participate in the intervention: (1) Central Zone Renal Program, Nova Scotia Health Authority, Halifax, Nova Scotia; (2) Foothills Medical Centre, Alberta Health Services, Calgary, Alberta; and (3) Royal Jubilee Hospital, Island Health, Victoria, British Columbia. Assessing the readiness of each site involved identifying a champion to spearhead the deprescribing intervention; at each site, this was a pharmacist. We hold regular meetings with all participating site partners to discuss the implementation approach, including limitations and strategies to address challenges at each respective site. The study team at TGH-UHN provided guidance and support to launch the project and throughout implementation.

Patient engagement

A total of 8 patient partners across British Columbia, Manitoba, Ontario, and Nova Scotia were consulted throughout the entire process and continue to play a vital role in knowledge mobilization activities for this research. We recruited patient partners through Can-SOLVE CKD, the STOPMed-HD webpage, and with support from existing patient partners. Patient partners are diverse in age, sex, geographic location, education status, and experience with chronic kidney disease and HD, offering a wide range of perspectives on this work. Their contributions have enhanced the quality of our research and broadened the reach of our knowledge translation efforts.

We engage patient partners through multiple avenues, including seeking input on study findings and manuscripts prior to submission for publication, data collection tools such as patient and clinician interview guide questions, and other materials such as videos, infographics, and 1-page summaries. We have implemented several strategies to address challenges related to scheduling and to promote the sustained involvement of patient partners. We established clear expectations regarding time commitment for participation (eg, 1-2 hours every 4-6 months), offering flexible meeting times, one-on-one meetings, and various communication channels (eg, email, telephone, and video meetings). As of 2025, we have introduced biannual patient partner meetings to promote relationship-building among patients and reduce potential power imbalances that may be present in meetings that include researchers and clinicians. These meetings provide opportunities for patients to learn about and provide feedback on recent study findings, discuss strategies for knowledge mobilization and dissemination, and share suggestions, including how they would like to be involved in study activities.

Indigenous cultural competency considerations

Indigenous people in Canada experience a significantly higher burden of chronic kidney disease and kidney failure compared with the general population.^46
-50 Indigenous engagement and reconciliation are essential components in reducing barriers to care and advancing equity. As such, we have made efforts to engage with Indigenous partners since the inception of our work. As a primarily white research team, we acknowledge that our privilege may unintentionally perpetuate historical injustices and power imbalances. We recognize that true allyship requires ongoing education, reflection, and action to reduce inequities. With this lens, we practice active listening and inclusiveness in all engagements with partners. We have worked with an Indigenous patient partner from the outset of the project, who helped inform our study design and deprescribing toolkit development. Recently, an additional Indigenous partner joined our team to inform the implementation phase of this project and contributed to reviewing results from our deprescribing intervention, providing insight into how the results could be refined for and shared with various audiences.

Steps 4 to 6 (Project Launch, Implementation, Monitoring, Evaluation, and Sustainability)

At TGH-UHN, the pharmacy team led the 6-month deprescribing intervention by first identifying patients suitable for deprescribing through medication review. Then, in conjunction with kidney doctors, they discussed deprescribing opportunities with patients using validated patient education tools.³⁶ The pharmacy team subsequently informed patients’ primary care physicians and community pharmacies of any medication changes through a “Dear Doctor” letter. This letter was tailored to each patient and included contact information for the STOPMed-HD team, should the patient’s circle of care have any questions or concerns. The letter, listing the deprescribed medications and any health changes, was documented in the patient’s electronic medical record. Finally, with support from kidney doctors and the nursing team, the pharmacy team led follow-up and monitoring activities. A nurse practitioner who participated in the intervention at TGH-UHN described the process as

very collaborative with pharmacy . . . our patients see multiple prescribers throughout the hospital so sometimes these medications were not even ordered by us . . . I would reach out to cardiology, endocrinology, and see if patients [still] needed that medication. Pharmacy would also reach out to prescribers.

We developed a comprehensive plan to evaluate our intervention using the RE-AIM (Reach, Evaluation, Adoption, Implementation, Maintenance) framework. As a widely used tool for evaluating disease management and health promotion programs,^51,52 the RE-AIM framework provides a structured approach to assess the intervention’s impact and its potential for sustainability and scalability. By applying the RE-AIM framework, we were able to establish clearly defined measures to assess the intervention’s safety, effectiveness, and feasibility for broader implementation. The framework served as a foundation for the development of our data collection plan, guiding both qualitative and quantitative data collection across each of the 5 RE-AIM domains. For example, to measure the intervention’s safety and effectiveness, we used our Monitoring Forms³⁵ to record the number of unexpected, clinically significant adverse events attributed to the deprescribing process for each study medication. To assess long-term maintenance of the intervention, we evaluated the usage of the toolkit beyond the study period through qualitative interviews with clinicians. The RE-AIM framework also informed our approach to data analysis and interpretation. Specifically, we mapped barriers and facilitators identified in our study to the framework, which may help to interpret and inform future efforts to implement sustainable deprescribing in HD settings.

To further support sustainability of the toolkit in practice, we collaborate with provincial agencies (eg, Ontario Renal Network) to drive awareness of deprescribing among kidney doctors and nurses by delivering presentations that highlight the benefits of deprescribing, outline the deprescribing process, and provide implementation strategies that can be adapted to local contexts.

Key Findings

Across the 4 study sites, preliminary findings indicate that a total of 256 patients taking 591 study medications have been included in our implementation, and 116 of these patients have attempted to deprescribe a total of 163 study medications. Deprescribing outcomes from the Toronto site have been published,⁵³ and findings from interviews with patients and clinicians who participated in the deprescribing intervention at the Toronto site have been accepted for publication. Table 1 summarizes key implementation barriers and facilitators to deprescribing identified at the Toronto site.

Table 1.

Barriers and Facilitators to Deprescribing in HD.

	Barriers to deprescribing	Facilitators to deprescribing
Patient level	• Fears of withdrawal or symptom recurrence • Previous negative experiences with deprescribing • Medication dependence • Lack of ongoing follow-up support • Intimidation by the term “deprescribing” • Disengagement among patients throughout deprescribing process	• Ongoing patient-provider communication (eg, risks and benefits of deprescribing) • Regular monitoring and follow-up • Reframing language in deprescribing discussions to focus on medication optimization and safety • Reassuring patients they have the option to restart their deprescribed medication at the original or reduced dose
Clinician level	• Time constraints among clinicians for deprescribing (eg, to apply deprescribing algorithms, discuss deprescribing with patients, follow-up) • Unclear roles and responsibilities among the hemodialysis care team	• Evidence-based guidelines and algorithms enhance knowledge and confidence among clinicians to deprescribe • Integrating deprescribing into routine care (eg, during medication review) • Defining roles and responsibilities among the HD care team • Designating a champion (eg, pharmacists) to lead deprescribing • Multidisciplinary collaboration
System level	• Time constraints among clinicians for deprescribing (eg, to apply deprescribing algorithms, discuss deprescribing with patients, follow-up) • Multidisciplinary collaboration • Fragmented electronic medical record (EMR) systems (ie, not all providers in patient’s circle of care have access to EMR) • Additional research on deprescribing outcomes in the hemodialysis population	• Cost savings from reduced adverse effects and decreased spending on medications • Sharing lessons learned across hemodialysis care teams to encourage buy-in• Additional research on deprescribing outcomes in the HD population

Note. HD = hemodialysis.

Implementation Considerations

Implementation of our intervention to date reveals several important considerations at the patient-, clinician-, and system- levels to support the long-term sustainability of deprescribing practices in HD settings. “Sustainability” refers to ongoing efforts to integrate deprescribing into routine practice, ensuring it becomes a standard component of care in HD units. To support the sustainability of this intervention, the study team will include the following considerations in an implementation package, which will be shared with key partners.

Patient-Level Considerations

Patient willingness to deprescribe is often influenced by their knowledge and beliefs about medications, as well as prior experiences with deprescribing.^20,54 Due to poor perceptions or negative experiences associated with deprescribing, we found that some patients were hesitant to participate in the deprescribing study. One way providers can support patient uptake of deprescribing is through their communication approach. For instance, providers can reframe messaging away from “deprescribing” and “taking away medications,” and instead focus on “improving understanding of medications,” “optimizing medication use,” and “ensuring medications are safe and needed.” In addition, when discussing opportunities for deprescribing medications and during follow-up care, providers can reassure patients that their health will be closely monitored and remind them that they have the option to restart their deprescribed medication at the original or reduced dose if they choose.

A notable barrier identified during the deprescribing process was that some patients were disengaged in their care. Specifically, some patients did not recall which medication(s) had been deprescribed or the reason behind the change, highlighting a potential need to improve education and sustain engagement with patients. Incorporating discussions about deprescribing into routine follow-ups may increase patient understanding and involvement in their care. Having providers regularly reference our patient toolkit and videos,³⁶ or other available resources, may also help to reinforce patient understanding and engagement.

Clinician-Level Considerations

Our intervention employed an evidence- and team-based deprescribing approach, using a deprescribing toolkit^35,36 to support clinical decision-making, assigning clear roles across the multidisciplinary HD team. Pharmacists acted as champions, using the toolkit to identify patients who might benefit from deprescribing. Pharmacists also engaged other clinicians in the deprescribing process during routine workflows, including best possible medication history,⁵⁵ medication reviews, and clinical rounds. This helped reinforce the value of streamlining medication management initiatives within HD units and emphasized its importance as a standard of care.

Clinicians reported that the toolkit was a useful guide to inform their decisions, aligning with existing research demonstrating that evidence-based tools can enhance knowledge and confidence in deprescribing.^19,56 However, some clinicians, including a pharmacist and 2 kidney doctors, expressed concerns that the time required to use the tools could limit their application in ongoing practice. Furthermore, while adequate communication and follow-up from trusted health care providers throughout the deprescribing process emerged as a key theme, time constraints may impede these efforts. As this toolkit was implemented as a research study, adaptations may be needed to sustain this intervention in everyday clinical practice. For instance, to identify opportunities for deprescribing, the algorithms were applied by the pharmacy team and reviewed by the multidisciplinary HD team, including kidney doctors and nurse practitioners during routine patient rounds. In addition, the monitoring forms were managed by the research team during the study, which may not be feasible in routine clinical practice. However, since clinical monitoring already occurs as part of routine care for patients in the HD unit, clinicians can use the toolkit’s monitoring forms³⁵ as reference guides during follow-up to ensure patient safety. Considering that clinician time constraints remain a barrier, further insight is needed to address potential workload challenges among clinicians, optimize workflows, and support deprescribing as a routine practice.

System-Level Considerations

One system-level consideration that may hinder care team collaboration is the possible lack of robust electronic medical record systems or established communication pathways at some HD sites, which serve as a mechanism to inform other health care specialists and family physicians of medication changes. In such cases, additional time and coordination may be required to ensure that the patients’ full circle of care is aware of deprescribing efforts.

Equity Considerations

Study populations at all 4 research sites include patients who vary by age, sex, ethnicity, education, and marital status. For example, at the Toronto site, 39% and 32% of the deprescribing participants and interviewees, respectively, were Black. Furthermore, 30% of patients participating in the intervention were of Asian descent, as were 32% of patients interviewed. Thus, deprescribing outcomes, surveys, and interviews will capture a range of patient experiences. This may increase the generalizability of our study findings, potentially supporting the safe and effective application of our deprescribing toolkit to diverse groups of people on HD. To date, our patient information tools have been translated to French, and as a next step in our process, we plan to translate our deprescribing resources for both patients and clinicians into several other languages. We will also ensure all resources are compliant with relevant provincial legislation, such as the Accessibility for Ontarians with Disabilities Act (AODA).⁵⁷

Furthermore, we are exploring modifications to the patient-facing deprescribing tools to address the unique cultural, linguistic, and health care needs of Indigenous communities. This includes translating the materials into Indigenous languages and ensuring the content is relevant, meaningful, and accessible. We may also sub-analyze our study findings by ethnic group, which may identify specific barriers to deprescribing experienced by certain groups, such as Indigenous people, and highlight an opportunity for future research. We will work with Indigenous patient partners to develop materials and strategies for sharing findings with Indigenous communities in a respectful and culturally sensitive manner.

Future Directions

Deprescribing in HD remains an inherently complex and, at times, time-consuming process. Further research is needed to identify scalable strategies that integrate deprescribing into routine care across diverse settings. Key areas of interest include whether awareness of deprescribing has increased among HD team members, whether patients are more engaged in managing their medications (eg, by asking more questions or expressing interest in optimizing their medications), and how deprescribing efforts can be tailored to local resources, health care staffing, and patient populations. Furthermore, since the research team facilitated collaboration amongst the HD team throughout the deprescribing intervention, additional research should explore how to maintain multidisciplinary collaboration in a typical clinical setting.

As we continue through the Can-SOLVE CKD Pathway to Implementation,⁴⁵ our focus is on scaling and sustaining deprescribing implementation across Canada. We will further refine our approach based on feedback from both clinicians and patients, and will apply and share our learnings through presentations and publications, such as our implementation package and a pharmaco-economic evaluation, to support future adoption. Successful implementation at additional HD sites will require recognizing and responding to the unique challenges present in different HD settings, including variability in resources, priorities, and patient populations. Therefore, it is essential to continue tailoring and adapting deprescribing efforts to suit local needs and contexts to promote long-term deprescribing success.

Footnotes

Acknowledgements

Thank you to University of Toronto pharmacy students Shaddy Guirguis, Anika Patel, Setayesh Yazdani, and Noah Zlotnik for assisting with implementation and evaluation of the deprescribing program, to Patrick Ng for his work in developing the research proposal, to Michelle Hampson and Selina Allu at Can-SOLVE CKD for assistance with manuscript preparation and review, and our Can-SOLVE CKD patient partners: Laura Bennett, Arlene Desjarlais, Sandra Holdsworth, Dennis McCann, Ashish Sharma, Katie Skidmore, Blair Waldvogel, and Erika Williams.

ORCID iDs

Angelina Abbaticchio

Madeline Theodorlis

Abhijat Kitchlu

Jo-Anne Wilson

Alexandra DeBusschere

Jenny Wichart

Caroline E. Stigant

Dan J. Martinusen

Alison J. Cheung

Marisa Battistella

Ethical Considerations

This study was approved by the University Health Network Research Ethics Board (Study ID: 21-5590) on November 4, 2021.

Consent to Participate

All participants provided written informed consent prior to participating in the deprescribing intervention and the qualitative interviews.

Consent for Publication

Not applicable.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Institute of Health Research—Strategy for Patient-Oriented Research (CIHR-SPOR), Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE) CKD Network (grant #KMI-181879); and the Kidney Foundation of Canada (grant #838159-21AHKRG).

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Abhijat Kitchlu administers funding from Amgen, Inc. and Janssen, Inc. to support the University Health Network Onco-Nephrology Fellowship Training Program and serves as President of the American Society of Onco-Nephrology. Dr Jo-Anne Wilson receives an Unrestricted Education Grant from Bayer. Dr Caroline E. Stigant serves as Medical Lead of the Planetary Health Working Group, BC Renal. A.A., M.T., M.S.C., L.S., N.S.D., E.Q., M.T., A.D., J.W., K.D., J.M.R., D.J.M., A.J.C., and M.B. declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of Data and Materials

Data available upon request. Please contact corresponding author Marisa Battistella (marisa.battistella@uhn.ca).

References

Chiu

Teitelbaum

Misra

de Leon

Adzize

Mehrotra

Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol. 2009;4(6):1089-1096. doi:10.2215/CJN.00290109.

Battistella

Fleites

Wong

Jassal

SV.

Development, validation, and implementation of a medication adherence survey to seek a better understanding of the hemodialysis patient. Clin Nephrol. 2016;85(1):12-22. doi:10.5414/CN108654.

Manley

McClaran

Overbay

, et al. Factors associated with medication-related problems in ambulatory hemodialysis patients. Am J Kidney Dis. 2003;41(2):386-393. doi:10.1053/ajkd.2003.50048.

Bortolussi-Courval

Podymow

Battistella

, et al. Medication deprescribing in patients receiving hemodialysis: a prospective controlled quality improvement study. Kidney Med. 2024;6(5):100810. doi:10.1016/j.xkme.2024.100810.

Reason

Terner

Moses McKeag

Tipper

Webster

The impact of polypharmacy on the health of Canadian seniors. Fam Pract. 2012;29(4):427-432. doi:10.1093/fampra/cmr124.

Vordenberg

Malani

Kullgren

JT.

Polypharmacy and deprescribing. JAMA. 2023;330(7):672. doi:10.1001/jama.2023.8872.

Fraser

SDS

Roderick

May

, et al. The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study. BMC Nephrol. 2015;16:193. doi:10.1186/s12882-015-0189-z.

Sullivan

Rankin

Jani

, et al. Associations between multimorbidity and adverse clinical outcomes in patients with chronic kidney disease: a systematic review and meta-analysis. BMJ Open. 2020;10(6):e038401. doi:10.1136/bmjopen-2020-038401.

Marin

Beresford

Pai

Espino-Hernandez

Beaulieu

Prescription patterns in dialysis patients: differences between hemodialysis and peritoneal dialysis patients and opportunities for deprescription. Can J Kidney Health Dis. 2020;7:2054358120912652. doi:10.1177/2054358120912652.

10.

Battistella

Jandoc

McArthur

Garg

AX.

A province-wide, cross-sectional study of demographics and medication use of patients in hemodialysis units across Ontario. Can J Kidney Health Dis. 2018;5:2054358118760832. doi:10.1177/2054358118760832.

11.

Salazar

Poon

Nair

Clinical consequences of polypharmacy in elderly: expect the unexpected, think the unthinkable. Expert Opin Drug Saf. 2007;6(6):695-704. doi:10.1517/14740338.6.6.695.

12.

Shah

Hajjar

ER.

Polypharmacy, adverse drug reactions, and geriatric syndromes. Clin Geriatr Med. 2012;28(2):173-186. doi:10.1016/j.cger.2012.01.002.

13.

American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. doi:10.1111/j.1532-5415.2012.03923.x.

14.

Leelakanok

Holcombe

Lund

Schweizer

ML.

Association between polypharmacy and death: a systematic review and meta-analysis. J Am Pharm Assoc (2003). 2017;57(6):729-738. doi:10.1016/j.japh.2017.06.002.

15.

Huang

Mallet

Rochefort

, et al. Medication-related falls in the elderly: `causative factors and preventive strategies. Drugs Aging. 2012;29(1):359-376. doi:10.2165/11599460-000000000-00000.

16.

Thompson

Farrell

Deprescribing: what is it and what does the evidence tell us. Can J Hosp Pharm. 2013;66(3):201-202. doi:10.4212/cjhp.v66i3.1261.

17.

Gerardi

Sperlea

Levy

SO-L

, et al. Implementation of targeted deprescribing of potentially inappropriate medications in patients on hemodialysis. Am J Health Syst Pharm. 2022;79(suppl 4):S128-S135. doi:10.1093/ajhp/zxac190.

18.

Reeve

Thompson

Farrell

Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017;38:3-11. doi:10.1016/j.ejim.2016.12.021.

19.

Gerlach

Michiels-Corsten

Viniol

, et al. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing–a qualitative study. BMC Fam Pract. 2020;21(1):183. doi:10.1186/s12875-020-01255-1.

20.

Mohottige

Manley

Hall

RK.

Less is More: deprescribing medications in older adults with kidney disease: a review. Kidney360. 2021;2(9):1510-1522. doi:10.34067/KID.0001942021.

21.

McIntyre

McQuillan

Bell

Battistella

Targeted deprescribing in an outpatient hemodialysis unit: a quality improvement study to decrease polypharmacy. Am J Kidney Dis. 2017;70(5):611-618. doi:10.1053/j.ajkd.2017.02.374.

22.

Huon

Sanyal

Gagnon

, et al. The cost of potentially inappropriate medications for older adults in Canada: a comparative cross-sectional study. J Am Geriatr Soc. 2024;72(11):3530-3540. doi:10.1111/jgs.19164.

23.

Patterson

Cadogan

Kerse

, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2012;16(5):CD008165. doi:10.1002/14651858.CD008165.pub2.

24.

Gallagher

O’Connor

O’Mahony

Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845-854. doi:10.1038/clpt.2011.44.

25.

Garfinkel

Mangin

Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648-1654. doi:10.1001/archinternmed.2010.355.

26.

Scott

Hilmer

Reeve

, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834. doi:10.1001/jamainternmed.2015.0324.

27.

Lindsay

Dooley

Martin

Fay

Kearney

Barras

Reducing potentially inappropriate medications in palliative cancer patients: evidence to support deprescribing approaches. Support Care Cancer. 2014;22(4):1113-1119. doi:10.1007/s00520-013-2098-7.

28.

Scott

Gray

Martin

Pillans

Mitchell

CA.

Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med. 2013;18(4):121-124. doi:10.1136/eb-2012-100930.

29.

Reeve

Wiese

MD.

Benefits of deprescribing on patients’ adherence to medications. Int J Clin Pharm. 2014;36(1):26-29. doi:10.1007/s11096-013-9871-z.

30.

Iyer

Naganathan

McLachlan

Le Couteur

DG.

Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging. 2008;25(12):1021-1031. doi:10.2165/0002512-200825120-00004.

31.

Hardy

Hilmer

SN.

Deprescribing in the last year of life. J Pharm Pract Res. 2011;41(2):146-151. doi:10.1002/j.2055-2335.2011.tb00684.x.

32.

Vasilevskis

Shah

Hollingsworth

, et al. Deprescribing medications among older adults from end of hospitalization through postacute care: a Shed-MEDS randomized clinical trial. JAMA Intern Med. 2023;183(3):223-231. doi:10.1001/jamainternmed.2022.6545.

33.

George

Joseph

Thomas

ETA

John

Siby

Nair

MM.

Active deprescribing program in chronic kidney disease patients undergoing haemodialysis. Nephrology (Carlton). 2021;26(11):890-897. doi:10.1111/nep.13936.

34.

Reeve

Hendrix

Shakib

Roberts

Wiese

MD.

Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793-807. doi:10.1007/s40266-013-0106-8.

35.

Lefebvre

PCK

Desjarlais

, et al. Development and validation of nine deprescribing algorithms for patients on hemodialysis to decrease polypharmacy. Can J Kidney Health Dis. 2020;7:2054358120968674. doi:10.1177/2054358120968674.

36.

Cho

PCK

Lefebvre

, et al. Development and validation of patient education tools for deprescribing in patients on hemodialysis. Can J Kidney Health Dis. 2023;10:20543581221150676. doi:10.1177/20543581221150676.

37.

Elbeddini

Zhang

CXY

. The pharmacist’s role in successful deprescribing through hospital medication reconciliation. Can Pharm J (Ott). 2019;152(3):177-179. doi:10.1177/1715163519836136.

38.

Parchman

Perloff

Ritter

Can clinician champions reduce potentially inappropriate medications in people living with dementia? study protocol for a cluster randomized trial. Implement Sci. 2022;17(1):61. doi:10.1186/s13012-022-01237-0.

39.

Bondurant-David

Dang

Levy

, et al. Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences. Int J Pharm Pract. 2020;28(6):635-642. doi:10.1111/ijpp.12674.

40.

Trenaman

Kennie-Kaulbach

d’Entremont-MacVicar

, et al. Implementation of pharmacist-led deprescribing in collaborative primary care settings. Int J Clin Pharm. 2022;44(5):1216-1221. doi:10.1007/s11096-022-01449-w.

41.

Kassis

Moles

Carter

Stakeholders’ perspectives and experiences of the pharmacist’s role in deprescribing in ambulatory care: a qualitative meta-synthesis. Res Social Adm Pharm. 2024;20(8):697-712. doi:10.1016/j.sapharm.2024.04.014.

42.

Kose

Endo

Hori

, et al. Association of pharmacist-led deprescribing intervention with the functional recovery in convalescent setting. Pharmazie. 2022;77(5):165-170. doi:10.1691/ph.2022.2323.

43.

Chan

Plakogiannis

Stefanidis

Chen

Saraon

Pharmacist-led deprescribing for patients with polypharmacy and chronic disease states: a retrospective cohort study. J Pharm Pract. 2023;36(5):1192-1200. doi:10.1177/08971900221097246.

44.

Lui

Wintemute

Muraca

, et al. Pharmacist-led sedative-hypnotic deprescribing in team-based primary care practice. Can Pharm J (Ott). 2021;154(4):278-284. doi:10.1177/17151635211014918.

45.

Allu

Beaucage

Donald

, et al. Collaborative implementation science: a Can-SOLVE CKD case example. JBI Evid Implement. 2024;22(4):418-421. doi:10.1097/XEB.0000000000000435.

46.

Harasemiw

Ferguson

Lavallee

, et al. Impact of point-of-care screening for hypertension, diabetes and progression of chronic kidney disease in rural Manitoba Indigenous communities. Can Med Assoc J. 2021;193(28):E1076-E1084. doi:10.1503/cmaj.201731.

47.

Kerr

Jaure

Stephens

, et al. Experiences of Indigenous patients receiving dialysis: systematic review of qualitative studies. Am J Kidney Dis. 2024;83(2):139-150. doi:10.1053/j.ajkd.2023.07.014.

48.

Komenda

Lavallee

Ferguson

, et al. The prevalence of CKD in rural Canadian Indigenous peoples: results from the First Nations community based screening to improve kidney health and prevent dialysis (FINISHED) screen, triage, and treat program. Am J Kidney Dis. 2016;68(4):582-590. doi:10.1053/j.ajkd.2016.04.014.

49.

Shah

Slater

Frymire

, et al. Use of the health care system by Ontario First Nations people with diabetes: a population-based study. CMAJ Open. 2020;8(2):E313-E318. doi:10.9778/cmajo.20200043.

50.

Gao

Manns

Culleton

, et al. Access to health care among status Aboriginal people with chronic kidney disease. Can Med Assoc J. 2008;179(10):1007-1012. doi:10.1503/cmaj.080063.

51.

Glasgow

Harden

Gaglio

, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. doi:10.3389/fpubh.2019.00064.

52.

Gaglio

Shoup

Glasgow

RE.

The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38-46. doi:10.2105/AJPH.2013.301299.

53.

Zlotnik

Abbaticchio

Theodorlis

, et al. Medication mindfulness: implementation and evaluation of a single-site, 6-month deprescribing intervention for patients on hemodialysis [published online ahead of print June 26, 2025]. Kidney360. doi:10.34067/KID.0000000884.

54.

Silva Almodóvar

Keller

Lee

, et al. Deprescribing medications among patients with multiple prescribers: a socioecological model. J Am Geriatr Soc. 2024;72(3):660-669. doi:10.1111/jgs.18667.

55.

Accreditation Canada Medication reconciliation as a strategic priority. https://physicians.nshealth.ca/sites/default/files/2022-05/NSHealth%20Medication%20Reconciliation%20One%20Pager.pdf. Accessed April 14, 2025.

56.

Linsky

Zimmerman

KM.

Provider and system-level barriers to deprescribing: interconnected problems and solutions. Public Policy Aging Rep. 2018;28(4):129-133. doi:10.1093/ppar/pry013.

57.

Government of Ontario. Accessibility for Ontarians with Disabilities Act, 2005, S.O. 2005, c. 11. Government of Ontario. https://www.ontario.ca/laws/statute/05a11#act-verion. Accessed April 14, 2025.