A realist evaluation of patients’ decisions to deprescribe in the EMPOWER trial

BACKGROUND AND OBJECTIVES Successful mechanisms for engaging patients in the deprescribing process remain unknown but may include: (1) triggering motivation to deprescribe by increasing patients' knowledge and concern about medications; (2) building capacity to taper by augmenting self-efficacy and (3) creating opportunities to discuss and receive support for deprescribing from a healthcare provider. We tested these mechanisms during theEliminating Medications through Patient Ownership of End Results (EMPOWER) () trial and investigated the contexts that led to positive and negative deprescribing outcomes. DESIGN A realist evaluation using a sequential mixed methods approach, conducted alongside the EMPOWER randomised clinical trial. SETTING Community, Quebec, Canada. PARTICIPANTS 261 older chronic benzodiazepine consumers, who received the EMPOWER intervention and had complete 6-month follow-up data. INTERVENTION Mailed deprescribing brochure on benzodiazepines. MEASUREMENTS Motivation (intent to discuss deprescribing; change in knowledge test score; change in beliefs about the risk-benefits of benzodiazepines, measured with the Beliefs about Medicines Questionnaire), capacity (self-efficacy for tapering) and opportunity (support from a physician or pharmacist). RESULTS The intervention triggered the motivation to deprescribe among 167 (n=64%) participants (mean age 74.6 years±6.3, 72% women), demonstrated by improved knowledge (risk difference, 58.50% (95% CI 46.98% to 67.44%)) and increased concern about taking benzodiazepines (risk difference, 67.67% (95% CI 57.36% to 74.91%)). Those who attempted to taper exhibited increased self-efficacy (risk difference, 56.90% (95% CI 45.41% to 65.77%)). Contexts where the deprescribing mechanisms failed included lack of support from a healthcare provider, a focus on short-term quality of life, intolerance to withdrawal symptoms and perceived poor health. CONCLUSION Deprescribing mechanisms that target patient motivation and capacity to deprescribe yield successful outcomes in contexts where healthcare providers are supportive, and patients do not have internal competing desires to remain on drug therapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01148186.