Delivering the right information to the right person at the right time to facilitate deprescribing in hospital: a mixed methods multisite study to inform decision support design in Australia

Abstract

ObjectivesTo inform the design of electronic decision support (EDS) to facilitate deprescribing in hospitals we set out to (1) explore the current processes of in-hospital medicines review, deprescribing and communication of deprescribing decisions with the patient’s general practitioner (GP), (2) identify barriers to undertaking these tasks and (3) determine user preferences for EDS.DesignMultimethod, multisite study comprising observations, semistructured interviews and focus groups.SettingGeneral medicine, geriatric medicine and rehabilitation wards at six hospitals in two local health districts in Sydney, Australia and primary care practices in one primary healthcare district in Sydney, Australia.Participants149 participants took part in observations, interviews and focus groups, including 69 hospital doctors, 13 nurses, 55 pharmacists and 12 GPs.Main outcome measuresObservational data on who was involved in medicines review and deprescribing, when medicines review took place, and what artefacts (eg, forms) were used. Participants reported perceptions of medicines review, polypharmacy and deprescribing and preferences for EDS.ResultsDeprescribing, undertaken during medicines review, was typically performed by a junior doctor, following a decision to deprescribe by a senior doctor. Key barriers to deprescribing included a perception that deprescribing was not the responsibility of hospital doctors, a lack of confidence among junior doctors and pharmacists in broaching this topic with senior doctors and a lack of patient engagement in the deprescribing process. In designing EDS, the tools, likely to be used by junior doctors, pharmacists and nurses, should be available throughout the hospitalisation and should comprise non-interruptive evidence-based guidance on why and how to deprescribe.ConclusionsDeprescribing decisions are complex and influenced by multiple factors. The implementation of EDS alone is unlikely to address all barriers identified. To achieve sustained improvements in monitoring of polypharmacy and subsequent deprescribing, a multifaceted intervention is needed.

Supporting deprescribing in hospitalised patients: formative usability testing of a computerised decision support tool

“…attitudes towards medications, beliefs about risks) [ 5 ]. These barriers are consistent with those identified in a study conducted across six Australian hospitals, where many healthcare professionals did not consider deprescribing to be their responsibility, felt insecure and uncertain about deprescribing, and reported that it did not fit with the timeframe and workflow of an acute admission [ 6 ].…”

“…General impressions of the CDS tool were positive and we hope that our revisions to the tool based on this testing will result in a tool that is used and integrated into current clinician work processes. We appreciate that the CDS tool is unlikely to address all the barriers we identified in our preliminary work [ 6 ]. However, if used as intended, the tool directly addresses key barriers, namely fitting with the timeframe and workflow of an acute admission, and uncertainty and insecurity about deprescribing.…”

“…Our CDS tool comprised multiple components within the electronic medical record, informed by a large number of focus groups and interviews with end-users [ 6 ], including review of paper prototypes. Central to our CDS tool is the concept of a DBI.…”

Communicating deprescribing decisions made in hospital with general practitioners in the community

“…The question guide was developed with input from pharmacists, experienced qualitative researchers and geriatricians, and pilot tested with junior researchers. Questions can be found in the supplementary data for a complementary study by our team (bmjopen‐2019‐030950supp001.pdf) 16 . This complementary study focussed on the perspectives and experiences of hospital doctors, pharmacists and nurses, while this current study focusses on perspectives of GP within the community.…”

Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings

“…14 But AMCs may also offer an ideal environment for deprescribing due to the collaborative environment, time for detailed medication histories, and engagement of families and caregivers in the deprescribing process during the hospital stay. 15,16 For older adults with cancer, the AMC can be an appropriate environment to study polypharmacy due to the multidisciplinary cancer care, focus on education/scholarship, and longer lengths of stay. Furthermore, research in the general geriatric population has shown that inpatient deprescribing initiatives are feasible and safe and that they are successfully continued after hospital discharge.…”