Background and Objectives: Medication exposure is a potential risk factor for falls and subsequent death and functional decline among older adults. However, controversy remains on the best way to assess medication exposure and which approach best predicts falls. The objective of the current study was to examine the association between different measures of medication exposure and falls risk among community-dwelling older adults. Research Design and Methods: This retrospective cohort study was conducted using Falls Free PA program data and a linked prescription claims data from Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly program. Participants were community-dwelling older adults living in Pennsylvania, United States. Three measures of medication exposure were assessed: (a) total number of regular medications (polypharmacy); (b) counts of potentially inappropriate medications derived from current prescription guidance tools (Fall Risk-Increasing Drugs [FRIDs], Beers Criteria); and (c) medication burden indices based on pharmacologic mechanisms (Anticholinergic Cognitive Burden, Drug Burden Index) all derived from claims data. The associations between the different medication risk measures and self-reported falls incidence were examined with univariate and multivariable negative binomial regression models to estimate incidence rate ratios (IRRs). Results: Overall 343 older adults were included and there were 236 months with falls during 2,316 activity-adjusted person-months (10.2 falls per 100 activity-adjusted person-months). Of the 6 measures of medication risk assessed in multivariate models, only the use of 2 or more FRIDs (adjusted IRR 1.67 [95% CI: 1.04–2.68]) independently predicted falls risk. Among the 13 FRID drug classes, the only FRID class associated with an increased fall risk was antidepressants. Discussion and Implications: The presence of multiple FRIDs in a prescription is an independent risk factor for falls, even in older adults with few medications. Further investigation is required to examine whether deprescribing focused on FRIDs effectively prevents falls among this population.

Few studies have systematically explored factors affecting medical students’ general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students’ general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline. From April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item. A total of 1264 responses were included in the analyses. The top three specialty choice were internal medicine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, “plan to inherit other’s practice” positively associated with choosing general practice, whereas “having physician parent” had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: “clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40–1.94)”, “community-oriented practice (aOR: 1.33, 95% CI 1.13–1.57)”, and” involvement in preventive medicine (aOR: 1.18, 95% CI 1.01–1.38)”. On the contrary, “acute care rather than chronic care”, “mastering advanced procedures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration. Our nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies.

Background: Despite accumulating evidence about the harm of polypharmacy in family medicine, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physicians' prescribing behavior. Methods: We conducted a survey of physicians at 5 family medicine residency practices and a linked health record review of their patients ≥65 years old. The determinants of physicians' mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model. Results: A total of 61 physicians (38 residents, 23 fellows/faculty) completed the survey, and 2103 visits by 932 patients seen by these physicians were analyzed. The mean numbers of prescriptions and PIMs per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider the number of medications (P = .007) and benefit/risk information for deprescribing (P = .017) when making prescribing decisions. Use of the Beers List was marginally significant in lower PIM prescribing (P = .05). Physicians' sex, duration of experience, and perceived confidence were not associated with prescribing patterns. Conclusions: Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers List, were associated with less polypharmacy and fewer PIMs.

Deprescribing has recently been applied to address polypharmacy, particularly among older adults. However, the characteristics of deprescribing that are likely to improve health outcomes have not been well studied. This study explored the experiences and perspectives of general practitioners and pharmacists with regard to deprescribing in older adults with multimorbidity. A qualitative study was conducted involving eight semi-structured focus group interviews with 35 physicians and pharmacists from hospitals, clinics, and community pharmacies. Thematic analysis was applied to identify themes using the theory of planned behavior as a guide. The results illustrated a metacognitive process, as well as influencing factors, through which healthcare providers commit to shared decision making for deprescribing. Healthcare providers acted on the basis of their attitudes and beliefs on deprescribing, the influence of subjective norms, and perceived behavioral control for deprescribing. These processes are influenced by factors such as drug class, prescribers, patients, deprescribing experience, and environment/education. Healthcare providers’ attitudes, beliefs, and behavioral control (along with deprescribing strategies) evolve in a dynamic interplay with experience, environment, and education. Our results can serve as a foundation for the development of effective patient-centered deprescribing to improve the safety of pharmaceutical care for older adults.

Importance: There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients.Objective: To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy.Design, Setting, and Participants: This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024.Intervention: The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons’ Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients’ primary care physicians and community pharmacists.Main Outcomes and Measures: The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events.Results: Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group).Conclusions and Relevance: In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy.Trial Registration: UMIN Clinical Trials Registry: UMIN000035265

Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.