CHARMER – a different kind of deprescribing intervention study

The CHARMER study of a proactive deprescribing intervention is different from previous studies and addresses five critical factors identified by prescribers and patients as being key to success, according to Professor Debi Bhattacharya, University of Leicester, UK who is one of the two co-chief investigators.

Many previous studies of proactive deprescribing interventions have failed to demonstrate positive outcomes. Bearing this in mind, CHARMER – Comprehensive geriatrician-led medication review – has developed a new approach.

Professor Bhattacharya says: “The intervention has taken us seven years of development. We started right from the beginning – understanding what patients, geriatricians and pharmacists feel about proactive deprescribing – what are the barriers? what are the enablers? – and then we’ve designed an intervention that specifically targets the things that they prioritised as needing addressing. For example, when we spoke to geriatricians and pharmacists, they said they felt very confident in their knowledge to be able to identify when medicine should be considered for stopping. So, unlike other interventions, we’re not providing any education or …. lists of medicines that should be considered for stopping. They actually said that would put them off”.

Electronic prompts and alerts have also been excluded as practitioners frequently complain of ‘prompt fatigue’.  They say, ‘You know, we’re constantly getting those for everything – it’s just yet another one for us to ignore’.

Five key elements emerged from the background work that Professor Bhattacharya’s team undertook and these had to be built into the CHARMER protocol. They were:

1. Ensure that practitioners feel that deprescribing is a priority for their employer
2. Address the misconception that patients are resistant to deprescribing
3. Overcome the feeling amongst pharmacists that it was safer to do nothing rather than to stop a medicine that’s currently causing no harm, even though it is likely that in the future it will cause harm
4. Provide protected time for pharmacists to meet with geriatricians to discuss patients that may benefit from deprescribing
5. Incorporate feedback so that practitioners see the results of their efforts.

The feedback scheme was co-designed with practitioners. When they have a discussion with a patient about proactive deprescribing and the patient agrees to try a discontinuation of a medicine, the details are entered into a computerised record. “That data then gets fed into a system that then reports back to them. They can see not just their performance as a hospital but the performance of all the other hospitals in the trial – and that, they said, was the best that they felt we could do in terms of them seeing some kind of positive outcome from their extra efforts”, says Professor Bhattacharya.

Small-scale testing of the CHARMER intervention in four hospitals has been completed and the main trial, which will be across 24 hospitals in England, is scheduled to start in the Autumn of this year (2023). The trial should finish in 2025 and the first results are expected in early 2026.

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