Pharmacists play a key role in deprescribing medications. Incorporation of this concept into pharmacy school curricula is important in ensuring that graduates can address the complex needs of an aging population. The aims of this study were to assess if and how student pharmacists were exposed to deprescribing within their curriculum, to assess students' perceptions regarding their attitudes, ability and confidence in deprescribing, and to assess if reported curricular exposure to this topic resulted in improved perceptions or objective knowledge assessment scores. An electronic survey was distributed to third-and fourth-year pharmacy students at 132 schools of pharmacy. The survey included three sections including: (i) demographics and questions on their exposure to deprescribing and other experiences within their curriculum; (ii) questions regarding their attitudes, ability, and confidence regarding deprescribing on a 5-point Likert-scale; (iii) a knowledge assessment on polypharmacy and deprescribing in the form of 12 multiple-choice questions. Likert-scale questions were analyzed as scales utilizing the mean score for items measuring student perceptions regarding deprescribing attitudes, ability, and confidence. Comparisons were made on each variable between students with and without curricular exposure to deprescribing using t-tests. Ninety-one responses were included in the analysis. Only 59.3% of respondents reported exposure to deprescribing in their didactic coursework. The mean scores on the polypharmacy and deprescribing knowledge assessments were 61.0% and 64.5%, respectively. Those with exposure to deprescribing concepts within their curriculum were more likely to agree that their school's curriculum prepared them to deprescribe in clinical practice (t(89) = −2.26, p = 0.03). Pharmacy schools should evaluate their curricula and consider the addition of specific deprescribing objectives and outcome measures for didactic and experiential training.

BACKGROUND Despite making great strides in improving the treatment of disease, the minimization of iatrogenic harm continues to be a major hurdle facing the healthcare system. Potentially inappropriate medications (PIMs) in older persons represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased healthcare costs. Deprescribing attempts to combat PIMs by systematically identifying and removing high risk medications from patients’ regimens. Attempts to operationalize deprescribing, however, have had mixed results. Complex contextual factors at play make the implementation process of these new interventions difficult. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex socio-technical systems. While initially intended for the nuclear power domain and interface design, AH has been used successfully to aid healthcare redesign of numerous systems such as design of decision support tools, mobile patient monitoring applications, and a telephone triage system. OBJECTIVE The aim of this manuscript is to refine our understanding about the primary care office in relation to a patient’s medication through the development of an abstraction hierarchy. Emphasis was placed on the elements related to medication safety in order to address the challenges of deprescribing in a more effective manner. METHODS The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by two authors and later given feedback from an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreed upon AH was achieved. A means-ends analysis was performed and described for nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. RESULTS This model depicts the various components which must be balanced and coordinated to provide medical treatment with limited healthcare resources in order to ensure patient medication safety. Understanding of the complex activities that occur in a primary care office depicted in this model may define areas in which deprescribing activities can be successfully completed. CONCLUSIONS After analysis of the generalized AH, recommendations for the development of an optimized medication management system in primary care were made. Numerous means-ends relationships can be identified using AH depending on the specific needs of the user. Individual practices can utilize the AH for clinic redesign to improve prescribing and deprescribing practices.

Background: Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective: This paper aims to refine our understanding of the primary care office in relation to a patient's medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods: The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results: This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions: Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.