Factors influencing deprescribing for residents in Advanced Care Facilities: insights from General Practitioners in Australia and Sweden

Abstract

BackgroundGeneral Practitioners (GPs) are responsible for primary prescribing decisions in most settings. Elderly patients living in Advanced Care Facilities (ACFs) often have significant co-morbidities to consider when selecting an appropriate drug therapy. Careful assessment is required when considering appropriate medication use in frail older patients as they have multiple diseases and thus multiple medication. Many physicians seem reluctant to discontinue other physicians’ prescriptions, resulting in further polypharmacy. Therefore it is relevant to ascertain and synthesise the GP views from multiple settings to understand the processes that might promote appropriate deprescribing medications in the elderly.The aims of this study were to 1) compare and contrast behavioural factors influencing the deprescribing practices of GPs providing care for ACF residents in two separate countries, 2) review health policy and ACF systems in each setting for their potential impact on the prescribing of medications for an older person in residential care of the elderly, and 3) based on these findings, provide recommendations for future ACF deprescribing initiatives.MethodsA review and critical synthesis of qualitative data from two interview studies of knowledge, attitudes, and behavioural practices held by GPs towards medication management and deprescribing for residents of ACFs in Australia and Sweden was conducted.A review of policies and health care infrastructure was also carried out to describe the system of residential aged care in the both countries.ResultsOur study has identified that deprescribing by GPs in ACFs is a complex process and that there are numerous barriers to medication reduction for aged care residents in both countries, both with similarities and differences. The factors affecting deprescribing behaviour were identified and divided into: intentions, skills and abilities and environmental factors.ConclusionsIn this study we show that the GPs’ behaviour of deprescribing in two different countries is much dependent on the larger health care system. There is a need for more education to both GPs and ACF staff as well as better cooperation between the different health care systems and appropriate monetary incentives for elderly care to achieve better conditions for deprescribing practice.

Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice

“…[21][22][23][24][25][26][27][28][29][30] Many of the suggested organizational changes we identified have previously been described, including targeted funding for annual medicines review, computer prompts and alerts, improving information flows between multiple prescribers, improving access to expert advice and user-friendly decision support, increasing availability of non-pharmaceutical alternatives, enhancing patient engagement in medicines management, and more research, education, and training to reduce the uncertainty in practice. [21][22][23][24][25][26][27][28][29][30] The novel contribution of our research lies in its focus on everyday primary care practice, where most ongoing prescribing occurs, and on the sociocultural influences at play-the importance to physicians of maintaining relationships with both patients and colleagues. Study findings draw attention to the need for a change in culture and in the attitudes and behaviors of both patients and physicians as well as a need to "warm the patient up" to the idea of deprescribing; to the possibility that less may be better.…”

“…Most research has focused on deprescribing in residential care settings, complex case examples, and understanding the views of patients. [21][22][23][24][25][26][27][28][29][30][31] We sought to explore the views of primary care physicians on the barriers to and facilitators of deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.…”

Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review

“…HCPs' attitudes towards deprescribing in older patients with limited life expectancy were explored through either individual interviews [25][26][27][28] or focus group interviews, [29][30][31][32] with one study conducting telephone interviews as well. 31 All but one study concerned older people residing in some type of aged care facilityie a rest home, 25 residential care, 26 advanced care facility, 27 nursing home, 28,29 residential aged care facility 30 or long-term care facility. 31 Patient profiles were used to facilitate deprescribing discussions in three studies.…”

“…25,30,32 While six studies concerned the use of multiple medications, two studies focused specifically on the use of hypnotics 28 and antidepressants. 29 All studies explored the views of physicians, mostly general practitioners (GPs), [25][26][27]31,32 while three studies also explored the views of pharmacists, 30,31 nurses 29 and long-term care facility staff. 31 Further, all but one study concerned HCPs working within primary care, either in general practice and/or some type of aged care facility.…”

“…For the remaining study, it was not specified whether the included HCPs were affiliated to primary and/or secondary care. 30 Although two of the studies were not purely qualitative, 27,30 only data concerning the qualitative parts of these studies are presented in this review.…”