Negotiating “Unmeasurable Harm and Benefit”: Perspectives of General Practitioners and Consultant Pharmacists on Deprescribing in the Primary Care Setting

Anderson, Kristen; Foster, Michele; Freeman, Chris; Luetsch, Karen; Scott, Ian A

doi:10.1177/1049732316687732

Cited by 66 publications

(191 citation statements)

References 35 publications

Supporting

Mentioning

186

Contrasting

Unclassified

Order By: Relevance

“…Older adults often need to consult with more than one prescriber in the course of managing multiple morbidities; this may result in an increased risk of poor communication regarding medications between prescribers and confusion about responsibilities . General practitioners view this as a potential barrier to enacting deprescribing.…”

Section: Resultsmentioning

confidence: 99%

“…Increased pill burden or the number of medications was a factor in triggering a medication review with a view to deprescribing . Some prescribers in another study thought that polypharmacy should be framed as a risk to patients who are aging in the same way as they would frame a discussion about the risk of other health problems such as stroke …”

Section: Resultsmentioning

confidence: 99%

“…This may result from patients not communicating important information regarding their medications . Furthermore, other prescribers, such as medical specialists, may not effectively communicate all their treatment plans (eg, medication indications and/or duration of treatment) to the GP …”

Section: Resultsmentioning

confidence: 99%

“…Their previous experiences of the clinical usefulness of medications and their belief that they generally cause few serious side effects resulted in them favouring continued prescribing over deprescribing . This bias towards prescribing was further promoted by the uncertain outcome of deprescribing …”

Section: Resultsmentioning

confidence: 99%

See 3 more Smart Citations

Deprescribing medications for older adults in the primary care context: A mixed studies review

Gillespie

Harrison

Mullan

2018

Health Science Reports

View full text Add to dashboard Cite

Aims: This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. Methods:A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies.Results: Thirty-eight articles were included, and 7 key categories were identified.The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. towards reducing polypharmacy (including deprescribing), from the perspective of both community-living older adults and GPs. This is important because, as mentioned earlier, deprescribing is most often considered in the context of the treatment of older adults. ConclusionsThe purpose of the current review is to build on Bokhof and JuniusWalker 24 work by investigating the factors that influence deprescribing from the perspective of both GPs and adults aged 65 years or older.Independent, community-living older adults are the focus of this review, as the majority of this group retain autonomy and are capable of being responsible for their own health decisions, 17 hence the importance of considering deprescribing from their perspective. Given the increasing evidence that is now available on this topic, a review that incorporates all study types is warranted. Interventions to promote deprescribing will require change on the part of both prescribers and older adults, so it is important to consider how their views interact to create the context where deprescribing discussions can take place. | METHODSA mixed studies review methodology was used as a guide to explore the factors that influence deprescribing. 27,282.1 | Eligibility criteria | Inclusion criteriaFull text primary research articles were included that were available in English, published between January 2000 and December 2017, and that investigated deprescribing or medication cessation/discontinuation in the primary care context for ...

show abstract

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 2 more Smart Citations

Deprescribing medications for older adults in the primary care context: A mixed studies review

Gillespie

Harrison

Mullan

2018

Health Science Reports

View full text Add to dashboard Cite

show abstract

“…28 Fostering trust, for example through a continuous therapeutic relationship between a professional and the patient-carer dyad, is likely to make this easier. 185 …”

Section: Minimally Disruptive Medicinementioning

confidence: 99%

Managing diabetes in people with dementia: a realist review

Bunn

Goodman

Jones

et al. 2017

Health Technol Assess

View full text Add to dashboard Cite

BackgroundDementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.ObjectivesTo identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.DesignRealist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.ParticipantsTwenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.Data sourcesThe following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing – UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).ResultsWe included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context–mechanism–outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.LimitationsThere is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.ConclusionsThis review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.Study registrationThis study is registered as PROSPERO CRD42015020625.FundingThe NIHR HTA programme.

show abstract

Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States

et al. 2018

View full text Add to dashboard Cite

and/or unnecessary medications in older adults is prevalent. This can lead to avoidable harms such as adverse drug reactions, falls, hospitalization, and mortality. Primary care physicians report that patient resistance to discontinuing medication use is a significant barrier to deprescribing. OBJECTIVE To describe the attitudes of older adults toward deprescribing and to determine whether individual characteristics are associated with these attitudes. DESIGN, SETTING, AND PARTICIPANTS For this population-based survey study of US Medicare beneficiaries 65 years and older, data were obtained from the Medication Attitudes module fielded through in-person interviews in round 6 of the National Health and Aging Trends Study (weighted response rate of round 6 was 88.5%). The questions in this module were drawn from the Patients' Attitudes Towards Deprescribing questionnaire and its revised version. The Medication Attitudes module was fielded to a random one-third (n = 2124) of the National Health and Aging Trends Study participants (weighted response rate of this module was 94.8%). MAIN OUTCOMES AND MEASURES Responses to 2 statements ("If my doctor said it was possible, I would be willing to stop one or more of my regular medicines" and "I would like to reduce the number of medicines I am taking") were the main outcomes of interest. RESULTS Of the 1981 Medicare beneficiaries included in the study, 1149 (55.2%, weighted) were women, and the majority (n = 715 [54.6%, weighted]) were 65 to 74 years old. A total of 1752 (92.0%, weighted) older adults reported being willing to stop taking 1 or more of their medicines if their physician said it was possible, and 1241 (66.6%, weighted) older adults wanted to reduce the number of medicines that they were taking. Older adults taking 6 or more medications had greater odds than those taking fewer than 6 medications of being willing to stop taking 1 or more of their medicines (adjusted odds ratio, 2.90; 95% CI, 1.74-4.82) and wanting to reduce the number of medicines that they were taking (adjusted odds ratio, 2.31; 95% CI, 1.71-3.13). CONCLUSIONS AND RELEVANCE Physicians considering deprescribing as part of comprehensive, patient-centered care should be reassured that a majority of older Americans are open to having 1 or more of their medicines deprescribed if their physician says it is possible, and more than two-thirds want to reduce the number of medicines that they are taking.

show abstract

Negotiating “Unmeasurable Harm and Benefit”: Perspectives of General Practitioners and Consultant Pharmacists on Deprescribing in the Primary Care Setting

Cited by 66 publications

References 35 publications

Deprescribing medications for older adults in the primary care context: A mixed studies review

Deprescribing medications for older adults in the primary care context: A mixed studies review

Managing diabetes in people with dementia: a realist review

Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States

Contact Info

Product

Resources

About