How confident are physicians in deprescribing for the elderly and what barriers prevent deprescribing?

Djatche, Laurence; Lee, Shaun Wen Huey; Singer, David; Hegarty, SE; Lombardi, Marco; Maio, Vittorio

doi:10.1111/jcpt.12688

Cited by 69 publications

(80 citation statements)

References 18 publications

(49 reference statements)

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“…By clarifying patients' and caregivers' views on medication value, our findings may also assuage prescribers' concerns regarding potential negative consequences of deprescribing that have been shown to impede their willingness to deprescribe potentially unnecessary or harmful medications. Barriers to deprescribing identified by prescribers in prior studies include assumptions about older adults' or their caregivers' views on medication use such as resistance to deprescribing, [15][16][17] potential to compromise the patientdoctor relationship if a medication is discontinued, 16 and patients' poor understanding of their medications. 16 Our findings counteract these assumptions in demonstrating that a number of factors would make a medication not worth taking for patients and caregivers and that they place a great deal of trust in a prescriber's recommendations.…”

Section: Discussionmentioning

confidence: 99%

“…16 This discordance in views may, in part, explain why polypharmacy and exposure to inappropriate medications remains prevalent. [15][16][17] Greater knowledge of patients' and caregivers' perspectives on medication value may empower healthcare providers to engage in shared decision making and initiate deprescribing conversations to mitigate the excess risk and costs associated with polypharmacy. Thus our objective was to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers.…”

Section: Introductionmentioning

confidence: 99%

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Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study

Pickering

Hamm

Dawdani

et al. 2020

J American Geriatrics Society

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OBJECTIVES Shared decision making is essential to deprescribing unnecessary or harmful medications in older adults, yet patients' and caregivers' perspectives on medication value and how this affects their willingness to discontinue a medication are poorly understood. We sought to identify the most significant factors that impact the perceived value of a medication from the perspective of patients and caregivers. DESIGN Qualitative study using focus groups conducted in September and October 2018. SETTING Participants from the Pepper Geriatric Research Registry (patients) and the Pitt+Me Registry (caregivers) maintained by the University of Pittsburgh. PARTICIPANTS Six focus groups of community‐dwelling adults aged 65 years or older, or their caregivers, prescribed five or more medications in the preceding 12 months. MEASUREMENTS We sought to identify (1) general views on medication value and what makes medication worth taking; (2) how specific features such as cost or side effects impact perceived value; and (3) reactions to clinical scenarios related to deprescribing. RESULTS We identified four themes. Perceived effectiveness was the primary factor that caused participants to consider a medication to be of high value. Participants considered a medication to be of low value if it adversely affected quality of life. Participants also cited cost when determining value, especially if it resulted in material sacrifices. Participants valued medications prescribed by providers with whom they had good relationships rather than valuing level of training. When presented with clinical scenarios, participants ably weighed these factors when determining the value of a medication and indicated whether they would adhere to a deprescribing recommendation. CONCLUSION We identified that perceived effectiveness, adverse effects on quality of life, cost, and a strong relationship with the prescriber influenced patients' and caregivers' views on medication value. These findings will enable prescribers to engage older patients in shared decision making when deprescribing unnecessary medications and will allow health systems to incorporate patient‐centered assessment of value into systems‐based deprescribing interventions. J Am Geriatr Soc 68:746–753, 2020

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study

Pickering

Hamm

Dawdani

et al. 2020

J American Geriatrics Society

View full text Add to dashboard Cite

show abstract

“…However, the feasibility of such an intervention in the perioperative setting is unclear since deprescribing requires time, patient engagement and close follow-up [30]. For example, general practitioners identified barriers such as a lack of knowledge about withdrawal side effects and discomfort about changing medications prescribed by another physician [31]. Whether internists or surgeons experience the same reluctance needs to be studied.…”

Section: Discussionmentioning

confidence: 99%

Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort

Forget

McDonald

Shema

et al. 2020

Drugs - Real World Outcomes

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Background Few studies have evaluated the prevalence of potentially inappropriate medications (PIMs) and its association with postoperative outcomes in a geriatric population in the preoperative setting. Objectives The purpose of this study was to evaluate the prevalence of PIMs in an older elective surgery population and to explore associations between PIMs and postoperative length of stay (LOS) and emergency department (ED) visits in the 90 days post hospital discharge, depending on frailty status. Methodology We performed a retrospective cohort study of older adults awaiting major elective noncardiac surgery and undergoing an evaluation in the preoperative clinic at a tertiary academic center between 2017 and 2018. We identified PIMs using MedSafer, a software tool built to improve the safety of prescribing. Frailty status was assessed using the 7-point Clinical Frailty Scale. We estimated the association between PIMs and postoperative LOS and ED visits in the 90 days post hospital discharge. Results The MedSafer software generated 394 recommendations on PIMs in 1619 medications for 252 patients. In total, 197 (78%) patients had at least one PIM. The cohort included 138 (51%) robust, 87 (32.2%) vulnerable and 45 (16.7%) frail patients. The association between PIMs and LOS was not significant for the robust and frail subgroups. For the vulnerable patients, every additional PIM increased LOS by 20% (incidence rate ratio 1.20; 95% confidence interval 0.90-1.44; p = 0.089) without reaching statistical significance. No association was found between PIMs and ED visits. Conclusion PIMs identified by the MedSafer software were prevalent. Preoperative evaluation represents an opportunity to plan deprescribing of PIMs.

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“…It is essential that students and juniors are educated about clinical decision making, patient factors and, importantly, barriers to deprescribing. There is increasing literature about barriers and enablers to deprescribing, including a systematic review, 7 surveys outlining concerns about stopping medicines, 5 and the potential for patient reluctance to stop medicines. 15 MBBS students reported a greater emphasis on polypharmacy in their undergraduate teaching as opposed to MPharm students, who ranked medication adherence as the second emphasis behind starting medicines.…”

Section: Discussionmentioning

confidence: 99%

“…Whilst embedding regular medication review into routine practice may support the WHO medication without harm challenge with respect to polypharmacy, barriers have been identified to making deprescribing decisions. [4][5][6] Anderson et al helpfully suggest further research to identify barriers and enablers that may inform the design of targeted deprescribing interventions. 7 Literature around medication review and deprescribing appears mostly aimed at senior clinicians.…”

Section: And Health Policy Advocates Undertakingmentioning

confidence: 99%

Education around medication review and deprescribing: a survey of medical and pharmacy students’ perspectives

Poots

Jubraj

Ward

et al. 2020

Therapeutic Advances in Drug Safety

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Research into the practice of medication review is developing across the world in response to the ever-increasing burden of inappropriate polypharmacy. Education, training and support of undergraduates and novice practitioners to equip them to participate in the medication review process could lead to long-term shifts in practice. The purpose of this study was to explore the awareness of pharmacy and medical undergraduates about medication review, deprescribing and polypharmacy, in order to inform improvement strategies. In November 2016, all final-year medical and pharmacy students at a London (UK) university were invited to complete a short questionnaire survey. Qualitative analysis inductively themed free-text comments and quantitative analysis used descriptive statistics to summarize responses, with chi-square tests used to indicate differences between the groups. The overall response rate was 34% (171/500). The terms ‘medication review’ and ‘polypharmacy’ were known to the students, whilst the term ‘deprescribing’ was unfamiliar with no difference between the groups. The term ‘medication review’ meant different things to the groups: pharmacy students suggested a focus on adherence and patient understanding, whilst medical students focused on interactions and whether medicines were still indicated. The groups differed in their perceptions of who they thought undertook reviews, who identifies potentially inappropriate medicines, who makes the final decision to deprescribe and the frequency of medication reviews. Both groups reported that on qualification they would not be comfortable stopping a medicine without discussion with a senior colleague, but would be comfortable prompting a senior colleague to review. Both groups had some awareness of medication review tools. The meaning of the term ‘medication review’ differed between the student groups. While medical students focused on clinical aspects, pharmacy students emphasized patient experience. Both groups anticipated a lack of confidence in deprescribing without senior support, highlighting the need for alignment between education and professional development syllabi in a way that combines the variety of professional perspectives. Prompts by juniors could lead to more medication reviews within existing practice, and may give them invaluable experience in reviewing medicines in their future careers as seniors.

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How confident are physicians in deprescribing for the elderly and what barriers prevent deprescribing?

Cited by 69 publications

References 18 publications

Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study

Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study

Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort

Education around medication review and deprescribing: a survey of medical and pharmacy students’ perspectives

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